An AI medical scribe for internal medicine
An internal medicine appointment rarely has one problem. Diabetes, hypertension, kidney function, a new symptom and a medication question can all land in fifteen minutes. ClearPass transcribes the visit, sorts the content into the structure you choose, often a problem list, and gives you an English draft to correct instead of a blank page.
Documenting a multi-problem visit
The challenge in internal medicine is not any single finding but keeping several threads apart. A good note shows, for each problem, what changed, what the evidence is, and what you decided.
The Problem list structure is built for that. Each problem gets its own history, results and plan. If you prefer SOAP or Full headings, the same content is arranged by section instead.
- Every active problem with its current status, not just the reason for today's visit.
- Medication reconciliation: what the patient actually takes, dose changes, and what was stopped and why.
- Lab trends with dates where the decision depends on direction: HbA1c, eGFR, sodium, haemoglobin.
- Preventive items discussed: vaccinations, screening, lifestyle.
- A clear line on follow-up and what should trigger earlier review.
Example: chronic disease review with a new symptom
A Problem list note, Concise. Invented patient and results.
1. Unintentional weight loss (new). 6 kg over 4 months without trying. Reduced appetite. No dysphagia, no change in bowel habit, no night sweats. Ex-smoker, 25 pack-years. Plan: FBC, CRP, LFTs, calcium, TSH, HbA1c, chest X-ray. Review in 2 weeks. 2. Type 2 diabetes. HbA1c 6.9% (7.3% previously). No hypos. Continue metformin. 3. Hypertension. BP 128/76. Continue current treatment. 4. Medication review. Stopped naproxen given eGFR 58 and age. Paracetamol for knee pain instead.
Items the patient mentions in passing, like the weight loss here, are the ones most often missing from a rushed note. A transcript catches them.
Internal Medicine templates
For typed cases, the Internal Medicine group includes imaging requests, diagnostic workup, chronic disease review, fever of unknown origin, unintentional weight loss, fatigue, anaemia, electrolyte and metabolic disturbance, pre-operative medical assessment, VTE and anticoagulation, infection or suspected sepsis, autoimmune screening, lymphadenopathy, and medication or polypharmacy review.
Subspecialty visits can use the specialty groups instead, for example cardiology, endocrinology or nephrology.
Letters and requests
Internists refer out often and write back to the referrer just as often. A referral letter, a medical report or patient instructions are each one click from the reviewed note, with no retyping.
When imaging or medicines need approval, the prior authorization letter mode drafts it, and letter of medical necessity explains the difference between the two. ICD-10 codes are suggested where your system uses them; see ICD-10 coding basics.
Using the Ask box on complex notes
After the draft appears, plain-language requests save editing time. Examples that work well in internal medicine: 'move the weight loss to problem 1', 'add a line that the patient declined the flu vaccine', 'write a referral to gastroenterology for the anaemia', or 'shorten the plan to one line per problem'.
Each request changes the note in place. Read the result, because the Ask box edits the draft and is not a second opinion.
Reviewing a multi-problem draft
- Each result sits under the right problem.
- The medication list matches what the patient takes, not what was prescribed years ago.
- Dose changes read in the right direction.
- Symptoms the patient denied are listed as denied.
- Nothing from a different patient. If you transcribe several patients in one session, confirm the split.
What ClearPass does not do
- It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
- It is not a medical device and does not make clinical decisions. It is a documentation aid.
- It does not connect to your EMR. The note is copy-ready text that pastes into any system.
Privacy
Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.
Questions
Which note structure suits internal medicine best?
Many internists use Problem list for complex visits and SOAP or Follow-up for simpler ones. You can also write your own structure once and reuse it.
Will Concise leave out important problems?
Concise keeps key points; Detailed keeps every clinical fact said. For multi-problem visits, try both in the trial. See concise vs detailed notes.
Can I ask it to reorganise the note?
Yes. Use the Ask box, for example 'split the plan by problem' or 'shorten the history'.
Does it check drug interactions?
No. It documents what was discussed and decided. It does not make clinical decisions.
What does ClearPass cost?
The 7-day trial is free, needs no card and simply ends after 7 days, with no automatic charge. After that there is one plan: $78 a month or $858 a year, with every visit transcribed.
Try it on your next clinic day
The full product for 7 days, with no card and no automatic charge. Then $78 a month or $858 a year. Pricing details.
Start free — 7 days, no card