Done whenyou are.
The draft is waiting when the consultation ends. Your format, your phrasing, codes suggested for you to approve. What is left is reading it.
A consultation produces more than one document.
A clinical note, a referral letter, a discharge summary, a sick note, a handout for the patient. All of them come from the same recording, and choosing another one later does not mean recording again.
- Recurrent headaches over three weeks, mostly late afternoon, behind the eyes.
- Ran out of antihypertensive cover for about a week before the repeat script.
- No visual disturbance, nausea or neck stiffness.
- Blood pressure elevated on today's reading, repeated after a rest period.
- No focal neurological deficit. Fundi not visualised.
- Headache, likely related to interrupted blood pressure control.
- Resume regular dosing, same agent and dose.
- Home readings twice daily for two weeks.
- Review in two weeks, sooner if symptoms worsen.
Dear Colleague
Thank you for seeing T.M., whom I reviewed today with a three week history of late afternoon headaches on a background of hypertension.
Her blood pressure was elevated today, following an interruption in her supply of about a week. There was no focal neurological deficit. I have restarted her usual agent at the same dose and asked for home readings twice daily.
I would be grateful for your opinion on whether the headaches warrant imaging if they persist once her pressure is controlled.
Kind regards
- Persistent headache with uncontrolled hypertension.
- Pressure settled over 48 hours once regular dosing resumed.
- Headache resolved without further analgesia.
- Usual antihypertensive, unchanged dose.
- Review with own doctor in two weeks, with home readings.
Your headaches are most likely happening because your blood pressure has been higher than usual, after the gap in your tablets.
- Take your tablet at the same time every day, even on days you feel well.
- Check your blood pressure morning and evening, and write it down.
- Come back in two weeks with those readings.
- The headache becomes severe or sudden.
- You have trouble with your vision, or weakness anywhere.
- T.M.
- Examined in person on the date of this certificate.
- Based on my own examination of the patient, not on reported history alone.
- Withheld at the patient's request.
- Unfit for duty for the period below.
- Two days, inclusive. Fit to return thereafter.
- Three weeks of late afternoon headaches, behind the eyes.
- Gap of about a week in antihypertensive cover.
- Pressure elevated, repeated after a rest period.
- No focal neurological deficit.
- Headache secondary to interrupted blood pressure control.
- Resume dosing, home readings twice daily.
- Review in two weeks.
Five layers decide how a note reads.
A note is not written to a house style and then trimmed to suit you. It is assembled in a fixed order of precedence, and that order is the product.
- Your template. The sections, their headings, and their order.
- Accuracy rules. Corrections you have made before, which nothing below may override.
- This note's settings. Anything you changed for this one consultation.
- Learned style. The wording habits taken from your edits.
- Your defaults. Everything you set once and stopped thinking about.
The rule that matters most is the second: a factual correction never gets demoted to a preference, and brevity never talks the model out of being right.
Prove every line.
The part of this we decided to build first, and the reason to choose it.
Tap any sentence in the draft and the words behind it appear, exactly as they were said in the room. You are not asked to trust the note. You are given the means to check it, line by line, in the time you have between patients.
Anything the model could not quote word for word is dropped rather than shown. A quote nobody can stand behind looks like verification while providing none, so this shows fewer sources than it could, on purpose.
The HPCSA's revised ethical rules put accountability for what AI writes in your name on you. This is what makes that accountability something you can actually discharge.
Say what kind of wrong it was.
You can always just edit the note. But you can also tell ScribeZA how it went wrong: something invented, something missed, a detail incorrect, something attributed to the wrong person, or something misheard.
That becomes a standing accuracy rule for your future notes, and an accuracy rule outranks every formatting preference you have set. It does not promise the same mistake never recurs. Nothing honestly can. It makes each one visible, countable and answerable.
It is a draft until you say otherwise.
Every note is marked as AI-assisted and carries no clinical or legal standing until a registered practitioner reviews and signs it. That sequence is deliberate, and it is not configurable. Once you sign, it is your record, held to the same standard as any note you have ever written.
Be first to use ScribeZA when it lands.
Free for the first wave of doctors, with a direct line to the person building it and real influence over what a South African medical scribe turns out to be.
Thank you.
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