Nem Scribe listens to the visit, writes the draft in Subjective, Objective, Assessment and Plan form, and proposes codes it has checked against the real ICD-10-CM catalogue. The clinician reads it, changes what they want and signs. Until then nothing is in the record.
Requires the AI entitlement and is switched on per clinic.
SubjectiveSore throat, three days. No fever.
ObjectivePharynx erythematous. Chest clear.
AssessmentLikely viral pharyngitis.
PlanFluids, rest, review if worse.
Sample data. Not a patient record.
A visit opens from the treatments list, and recording begins on the encounter screen, never from the list. The per-visit consent line is shown before anything is captured. If consent is declined, recording is unavailable and the clinician documents the visit the way they always have.
Audio is captured either in live chunks as the visit runs or as one whole file afterwards. The transcript carries a role beside each line, Clinician, Patient or Other. When the role is not clear the line is left unlabelled rather than guessed at, because a wrong label on a clinical transcript is worse than none.
The note comes back in Subjective, Objective, Assessment and Plan sections. Alongside it, proposed ICD-10-CM codes, coding-guideline recommendations from deterministic rules, care plan component hints drawn from the clinic’s own templates, and any procedure the visit describes, matched to the clinic’s catalogue.
There is no accept-all. Each section, each code and each suggestion is accepted or rejected on its own. Filing writes a note attributed to the reviewing provider, and an append-only clinical update when the patient has an active care plan. Rejected elements leave no clinical record at all.
Nothing Scribe produces is a record. A draft sits beside the visit until a clinician works through it element by element, and there is no accept-all control anywhere on the review screen. Filing writes a note attributed to the reviewing provider, and an append-only clinical update when the patient has an active care plan. A code the provider adopts is written into the note body as coding they adopted; it is never written to a diagnosis, condition or claim table by anything in this product. Rejected elements are dropped and leave no clinical record. Requests carrying patient information are refused outright unless the model provider is covered by a business associate agreement that is current.
The visit transcript is working text, and it is not kept forever. Each clinic sets how long its own transcripts are held after the note is filed, inheriting an organisation setting when it has set nothing itself; the default is 30 days. The clock starts at filing rather than at the end of the recording, because until the note is filed the transcript is what the clinician is reading from. The filed note itself is the clinical record and none of this touches it.
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Filing writes one note, attributed to the reviewing provider and stamped when they filed it. What reaches the record is a provider-authored note, because that is what it is.
When the patient has an active care plan, filing adds one append-only clinical update through the same path every other clinical narrative entry uses. It never edits or replaces an earlier entry. Care component hints are read from the clinic’s own template library and stay hints: no plan is created and no component is linked to a patient.
An adopted code is written into the note body as coding the provider adopted. It is not posted to a claim, a diagnosis table or a condition record by anything in Scribe, so a biller reads it from the note in the ordinary way. An accepted procedure updates the treatment record through the treatment screen’s own audited actions, at the clinic’s own catalogue price.
Nem Scribe requires the AI entitlement, and it is switched on per clinic rather than across an account. A clinic without the entitlement can use every other part of Nem exactly as before; Scribe simply does not run.
No. A draft is not a note. One module files, it runs when a clinician has reviewed the draft and chosen to file, and the note it writes is attributed to that provider. Elements the clinician rejected are dropped and leave no clinical record.
A model can propose one, and the server will not store it. Every proposed code is looked up in the loaded code catalogue before it is saved; anything the catalogue does not have is dropped, the description shown is the codebook’s own, and the review screen says how many were dropped.
The consent line is shown before any audio is captured, and it is separate from any programme consent the clinic already holds. If consent is declined, recording is unavailable for that visit and the clinician documents it manually. A transcription failure never blocks manual documentation either.
The review screen says so, calmly and before the draft is read, with the proportion stated in plain rounded terms rather than a false decimal. A short transcript is treated as a fact about the note rather than as an error worth hiding.
Scribe requires the AI entitlement and is enabled per clinic. Requests that carry patient information are refused unless the model provider is covered by a business associate agreement that is current, and a refusal is reported as a refusal rather than dressed up as an outage.
We will record a mock consultation, show the transcript, the draft and the codes it proposes, and walk through exactly what a clinician has to do before any of it is in a record.
