Create a note
Simplify makes it easy to create notes in seconds, this guide best shows you how to customize those seconds to produce the best note for you!
Last updated
Simplify makes it easy to create notes in seconds, this guide best shows you how to customize those seconds to produce the best note for you!
Last updated
Tutorial Video:
The AI Medical Scribe is a powerful tool designed to streamline medical documentation by transforming patient encounters into suggested formatted clinical notes. Whether you're recording a live patient visit, documenting case details, or creating structured medical reports, the AI Medical Scribe helps healthcare professionals save time and improve documentation quality.
Medical/Non-Medical Toggle
Switch between medical documentation mode and standard document creation
Content Area
Main text input where you can type or view recorded encounter information
Create Button
Generates the suggested clinical note based on your recorded encounter
Draft Button
Saves your current encounter for later completion
Listen Button
Starts/stops the encounter recording feature
Category Selector
Assigns your document to a specific category or team
Toggle between two primary modes:
Medical Mode: Creates HIPAA-compliant suggested medical documentation with appropriate formatting, sections, and coding
Non-Medical Mode: For general documents without protected health information
The draft system allows you to save encounters in progress and access them later:
Select Draft: Choose from previously saved encounter drafts organized by date and category
Save Draft: Store your current encounter as a draft that can be resumed later
Team Drafts: Access encounter drafts shared within your organization or team
Direct Draft Creation: Press "Listen" to record an encounter and then "Draft" (without needing to stop recording first – the system handles the transition automatically)
Multiple ways to document patient encounters:
Manual Entry: Type encounter details directly into the content area
Encounter Recording: Use the "Listen" feature to record the patient encounter in real-time
File Upload: Import encounter data from supported file types (JPEG, PNG, PDF, DOCX)
Template-Based: Start with pre-configured templates for faster clinical documentation
Control the structure of your medical note:
Automatic Sections: Let the AI determine appropriate clinical sections based on encounter content
Manual Selection: Choose specific sections to include from preset medical categories
Custom Sections: Create your own section types for specialized documentation
Section Ordering: Organize medical information logically by selecting required sections
Powerful customization tools for consistent medical documentation:
Templates: Save and apply predefined combinations of sections, rules, and formatting
Rules: Create clinical instructions for the AI to follow when generating notes
Section-Specific Rules: Apply special formatting or content guidelines to particular sections
Template Sharing: Access templates across your healthcare organization or team
Record Encounter: Use the "Listen" button to record the patient encounter or type encounter details
Click Create: Generate your medical note with AI assistance
Export for review: Wait for the screen to flash green then close out of the create popup to see and review your note
Click the "Listen" button to start recording the patient encounter (make sure to gain informed consent from patient)
The system will capture the entire encounter in real-time, converting speech to text in the content area
When the encounter is complete, you can:
Click "Create" directly to generate the medical note (no need to stop recording first)
Click "Draft" to save the encounter for later completion (no need to stop recording first)
Click "Stop" on the Listen button if you prefer to review before creating or drafting
Templates save time by applying predefined clinical configurations:
Select Template: Choose from available clinical templates in the dropdown
Create Template: Save your current configuration as a new template
Give your template a meaningful name related to the encounter type
Select sections and rules to include for this encounter type
Add section-specific instructions if needed
Apply Template: Templates automatically configure sections and rules for consistent documentation
For more in-depth work with templates please contact our team for help
Click "More Options" to access additional features:
File Upload: Attach and process clinical images, PDFs, or Word documents
Email Configuration: Specify recipient email(s) for secure delivery of notes
Vitals Input: Add patient vitals data in structured format
Story Mode: Enable for narrative-style documentation (Non-Medical mode)
The logs section provides real-time updates during note creation:
Status Indicators: Shows active processes and completion status
Error Reporting: Displays any issues encountered during processing
Creation Progress: Tracks the note generation process
Streamlined Workflow: Use "Listen" → "Create" or "Listen" → "Draft" without stopping in between for maximum efficiency
Regular Saving: Use the "Draft" button frequently to prevent losing work
Template Usage: Create templates for common encounter types
Section Selection: Choose only necessary clinical sections for cleaner notes
Clear Audio: Ensure good audio quality during patient encounters for optimal transcription
Review Content: Always verify AI-generated content for clinical accuracy before finalizing
All medical documentation is HIPAA-compliant through secure processing
Email delivery uses encrypted transmission for protected health information
The system does not guarantee the accuracy of suggested codes or clinical content - always review before finalizing
Patient encounter recording works best in quieter clinical environments with minimal background noise
Please review the Patient Disclosure requirements for your jurisdiction before recording encounters
Legal Disclaimer: **Simplify AI provides general information only, not billing, coding, or medical advice. We do not guarantee the accuracy of the suggested codes or material generated by Simplify or that the use of such codes or material will result in payment or reimbursement or that they will be accurate in anyway. The platform is not a substitute for billing and coding advice from qualified billers and codding experts.
