SpecScribe listens to your session and drafts the note for you to review and sign — so Canada's clinicians can get back to what they trained for: caring for patients.
Three steps. No templates to click through. Nothing is final until you sign.
After you record the patient's consent, SpecScribe transcribes your natural clinical conversation as it happens. No dictation commands or templates to navigate during the encounter.
SpecScribe drafts a specialty-specific note (SOAP, DAP, BIRP), suggests billing codes (beta) and can write a patient handout once the visit ends, for you to review.
Where an Epic-based EHR connection has been set up, your signed note can be filed to the chart via SMART on FHIR. Otherwise, export it as a PDF.
Where an Epic-based EHR connection has been set up, SpecScribe pulls problem lists and medications from the chart, and summarizes your practice's signed notes and consult letters from the past year, so you spend the visit listening to your patient, not hunting through charts.
EHR sync — schedules pulled in, and active problems and medications added to each note's context.
Patient Recap — a one-glance summary of relevant signed notes from the last 12 months.
Cross-referral context — includes signed consult notes from other providers in your practice.
Patient #4821 — M.T., 54F
Seen last: Feb 3, 2026
Active Conditions
Generalized anxiety disorder · Hypertension (controlled) · Hypothyroidism
Current Medications
Sertraline 100mg · Ramipril 5mg · Levothyroxine 75mcg
Recent Consult
Psychiatry consult — Jan 12, 2026 · No med changes recommended
SpecScribe adapts to your specialty and clinical reasoning style — not the other way around. Whether you document in DAP, SOAP or BIRP format, the AI structures the note to match your saved preferences and specialty templates.
Always your note — AI-written text is highlighted until you edit it, and nothing is final until you sign.
Format memory — the AI remembers your preferred physical exam normals, section order, and abbreviation style.
Lay-language patient summaries — generate plain-language handouts in English or French for patients to take home.
Built-in scoring tools — PHQ-9, DASH, CHA₂DS₂-VASc, ECOG and more, calculated and inserted into the note.
Subjective
Patient reports worsening low mood over the past 3 weeks. Sleep is disrupted — averaging 4–5 hrs/night. Denies active suicidal ideation. PHQ-9 score today: 14 (moderate).
Objective
Alert and oriented ×3. Affect flat, psychomotor slowing observed. No formal thought disorder. Cognition grossly intact.
Assessment
Major depressive disorder, recurrent moderate episode (F33.1). Partial response to current Sertraline dose.
Plan
Medication plan as discussed in the visit — clinician to confirm. Referral to counselling. Follow-up in 4 weeks or sooner if symptoms worsen.
For Alberta (AHCIP) billing, SpecScribe reviews each note for possible gaps in complexity, time units, modifiers and virtual-care rules, and suggests service codes for you to check against the current Schedule of Medical Benefits. You decide what to bill.
Service code suggestions — the AI suggests service codes based on what's documented, each with a confidence level for you to check.
Time-based billing alerts — compares recorded visit time with time-based codes and flags extra units the documentation may support.
Modifier prompts — flags notes where after-hours, emergency, or virtual-care modifiers may apply.
Always a draft — you review and submit. SpecScribe never auto-submits a claim on your behalf.
Possible billing gap flagged
The documented visit time may meet the criteria for 03.04C. Check the note against the SOMB criteria — you decide what to bill.
Starting with the specialties that carry the heaviest documentation load. Templates are in clinical review.
DAP, BIRP, SOAP and narrative notes for therapists, counsellors and social workers, from intakes and biopsychosocial assessments to treatment plans and discharge summaries.
Templates for registered psychologists, including test interpretation, risk assessment and collateral contact notes. The drafting instructions leave out prescribing and refer to DSM-5-TR codes by number.
DAP, SOAP and BIRP note formats. PHQ-9, GAD-7 and MADRS scores calculated and inserted into the note. Psychiatric templates include a risk-assessment section for you to complete.
Procedure notes and operative reports. Functional outcome measures (ASES, DASH, KOOS, ODI) scored for you. Workers' compensation and IME note templates.
Biopsy and excision note templates with ICD-10-CA code suggestions for you to confirm. Lesion documentation by site, size and morphology.
Consultation, follow-up, stress test, echo and procedure report templates. CHA₂DS₂-VASc and HAS-BLED scoring built in.
Staging and treatment plan notes, ECOG performance status, toxicity grading and tumour board summaries. The AI is blocked from writing chemotherapy doses; you enter them.
Opioid treatment agreement and medication-management documentation, with checks for your province's prescription monitoring and secure-prescription programs. The AI is blocked from suggesting opioid dose changes.
SpecScribe drafts the clinical justification and step-therapy history from your encounter notes and fills a payer-specific PDF, so you start from a complete draft instead of a blank form.
Pre-filled forms — clinical justification drafted from encounter data for you to check, not from memory.
Missing-documentation check — lists what the payer is likely to ask for that the note doesn't yet support, before you submit.
PDF generation — PDF documents laid out for supported payers' forms, ready for you to review, sign and submit.
Authorization For
MRI lumbar spine — suspected disc herniation L4-L5
Clinical Justification
6-week conservative management failed (physiotherapy × 12 sessions, NSAIDs). Progressive radiculopathy with diminished L5 reflex. MRI required to rule out surgical pathology.
Supporting Documentation
3 encounter notes attached · Physiotherapy discharge summary · X-ray report (Jan 2026)
Your clinic keeps its obligations under PIPEDA and your province's health-privacy law, such as Ontario's PHIPA or Alberta's HIA. SpecScribe supports them: patient health information is stored in Canada, the app refuses to send it to storage or transcription services outside Canada, identifiers are removed before AI drafting on Anthropic's Claude API in the US, and access to patient records is logged. It also keeps records for your province's retention minimums and lists your province's reporting duties and regulators on your compliance page.
General information, not legal advice.
Supports PIPEDA and provincial health-privacy obligations
Every practice accepts a data agreement under its province's law; we capture per-encounter consent and delete audio at sign-off, to support your obligations for your records.
Health information stored in Canada
Patient health information is stored in Canada, and the app and transcription run in Canada. AI drafting runs on Anthropic's Claude API in the United States, after identifiers are removed.
AES-256-GCM Encryption
PHI encrypted at the application layer before database write, including transcripts, notes and clinical fields.
Audit Trail
Access to patient records is logged with user, timestamp, IP address, and resource, in a tamper-evident hash chain.
SpecScribe works alongside or replaces traditional dictation. Instead of dictating into a recorder, you simply have your normal conversation with the patient. SpecScribe transcribes it and drafts a structured note in your preferred format for you to review and sign.
The templates ask the AI to keep each clinical problem under its own assessment and plan, and the per-encounter billing review flags documented problems that have no matching code. Review multi-problem notes carefully. As with every note, you edit and sign.
Every AI output is a draft that requires your review and approval. The note editor highlights AI-suggested content in a distinct colour, making it easy to spot and correct any inaccuracies before finalization. You maintain full clinical authority.
You can start as soon as your account is set up. Import your patient list, then up to 90 days of past encounters from a CSV export (or, in beta, from a connected Epic-based EHR), so you start with your own data. We guide you through setup.
Yes, as long as your device's microphone can hear both sides of the call. When a note describes a virtual visit, the billing review flags it for virtual-care codes or modifiers.
Try SpecScribe in your practice. 30-day free trial — no credit card required.