Notermed

Specialties

AI scribe for cardiology clinics

A cardiology note lives or dies on its results section. Notermed’s cardiology format has a place for the ECG (rate, rhythm, intervals, ischemic changes), the echocardiogram (LVEF, chamber sizes, valves, wall motion), stress test and catheterization findings, Holter or event monitor data, and the labs that matter here: troponin, BNP or NT-proBNP, lipids, INR. The report impression is preserved as written, not paraphrased.

  • Built-in formats1
  • Sections across them14
  • Structure reviewed

What a cardiology note captures

Every line below is a field in the built-in cardiology format. The draft fills a line only when the visit spoke to it; a section with nothing stated is left out rather than padded.

  1. 01

    Chief Complaint (CC)

    • A short reason for the visit
    • For example chest pain, palpitations, heart failure follow-up
    • Or pre-op cardiac clearance
  2. 02

    History of Present Illness (HPI)

    • Reason for referral or follow-up
    • Chest pain: exertional or at rest, radiation, associated symptoms
    • Dyspnea and NYHA class
    • Orthopnea, paroxysmal nocturnal dyspnea, edema
    • Palpitations, presyncope, syncope, claudication
    • Interval hospitalizations and procedures
    • Adherence and symptom control
    • Study results the clinician reviewed aloud
  3. 03

    Past Medical History (PMHx)

    • MI, PCI or stents, CABG
    • Atrial fibrillation, heart failure
    • Hypertension and hyperlipidemia
  4. 04

    Past Surgical History (PSHx)

    • Prior surgery, where provided
  5. 05

    Family History (FHx)

    • Premature CAD, sudden cardiac death, cardiomyopathy
  6. 06

    Social History

    • Smoking status, with pack-years when given
    • Alcohol and drug use
    • Activity level
  7. 07

    Review of Systems (ROS)

    • Only the systems raised, with the findings actually stated
  8. 08

    Medications

    • Antiplatelets, anticoagulants, statins
    • Beta-blockers, ACE, ARB or ARNI
    • Diuretics and antiarrhythmics
  9. 09

    Allergies

    • Allergies as stated
    • No known allergies only when someone said so
  10. 10

    Vitals

    • BP, with arm and position when given
    • HR and whether the rhythm is regular
    • RR, SpO2
    • Height, weight, BMI, weight trend
  11. 11

    Physical Exam

    • GEN, NECK and JVP
    • CV: rate and rhythm, heart sounds, murmurs and gallops
    • RESP, ABD
    • EXT: edema, pulses, perfusion
    • Only findings actually stated or dictated
  12. 12

    Results / Diagnostics

    • ECG: rate, rhythm, intervals, ischemic changes
    • Echocardiogram: LVEF, chamber sizes, valves, wall motion
    • Stress test
    • Cardiac catheterization: vessel findings and interventions
    • Holter or event monitor
    • Labs: troponin, BNP or NT-proBNP, lipids, INR, electrolytes, renal function
    • The report impression preserved as written
  13. 13

    Assessment

    • A problem list of the diagnoses the clinician stated
    • ICD-10 codes flagged for billing verification
    • Severity or class, only where the clinician stated it
  14. 14

    Plan

    • Grouped by problem, numbered
    • Ischemic: antianginal, antiplatelet, statin changes
    • Ischemic: stress test or catheterization, revascularization referral
    • Heart failure: beta-blocker, ACE, ARB, ARNI, MRA, SGLT2i, diuretic
    • Heart failure: daily weights, sodium and fluid counseling, echo interval
    • Arrhythmia: rate or rhythm control, anticoagulation decision
    • Arrhythmia: CHA2DS2-VASc when stated, monitor, EP referral or ablation
    • Risk factors: blood-pressure and lipid targets, lifestyle counseling

The format

One built-in format

  1. Cardiology Note

    Cardiology encounter note (ischemic, heart failure, arrhythmia).

    14 sections

Questions from cardiology clinics

How does it handle an echo report I read out during the visit?
The Results / Diagnostics section captures LVEF, chamber sizes, valves and wall motion as you state them, and keeps the report impression preserved as written. Nothing is inferred beyond what was said.
Does it separate the ECG from the rest of the results?
ECG rate, rhythm, intervals and any ischemic changes are their own line under Results / Diagnostics, alongside separate lines for stress test, cardiac catheterization (vessel findings and interventions) and Holter or event monitor.
Which labs does the format expect?
Troponin, BNP or NT-proBNP, lipids, INR, electrolytes and renal function. If a lab was not mentioned, its line is left out; the draft never fills a value the visit did not supply.
Is the format fixed, or can my clinic change it?
You can add formats of your own, and save your own copy of any built-in one. The built-in one is a starting point with the cardiology vocabulary already in place.

What holds true for your patient data

These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.

  • A BAA first

    We sign a Business Associate Agreement with your clinic before any patient data is processed.

  • US servers only

    Patient data is stored and processed only on servers in the United States.

  • Encrypted throughout

    Recordings, transcripts and notes are encrypted in transit and at rest.

  • Never training data

    Patient conversations are never used to train AI models.

  • Yours to sign

    Every note is a draft until the clinician reviews it and signs it.

This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.

See it on one of your own cardiology visits

Bring a consultation. We will record it, show you the draft in your format, and tell you plainly if Notermed is not a fit yet.

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