Notermed

Specialties

AI scribe for rheumatology clinics

A rheumatology note is built on serology, and a template without lines for it turns a workup into a paragraph. Notermed’s rheumatology format records inflammatory markers (ESR, CRP), autoantibodies (ANA with pattern, RF, anti-CCP, anti-dsDNA, anti-Sm), ANCA, HLA-B27 and uric acid, synovial fluid analysis, and X-ray, ultrasound or MRI findings with the impression. Each on its own line, and only when it was said.

  • Built-in formats1
  • Sections across them12
  • Structure reviewed

What a rheumatology note captures

Every line below is a field in the built-in rheumatology 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

    • The primary reason for the visit, as stated
  2. 02

    History of Present Illness

    • Onset, duration, quality, and severity
    • The specific joints involved
    • Aggravating and alleviating factors
    • Associated symptoms and progression
    • Morning stiffness duration and gel phenomenon
    • Enthesitis and dactylitis
    • Raynaud phenomenon and sicca symptoms
    • Constitutional symptoms
  3. 03

    Past Medical History

    • Prior diagnoses such as RA, SLE, gout, OA, psoriasis
    • Surgeries and hospitalizations
  4. 04

    Medications

    • Current medications with dose, frequency, and duration
    • Grouped as DMARDs, biologics, NSAIDs, steroids where clear
  5. 05

    Allergies

    • Drug and environmental allergies, and the reactions
  6. 06

    Social History

    • Smoking, alcohol, recreational drugs
    • Occupation and living situation
  7. 07

    Family History

    • Autoimmune, psoriasis, or rheumatologic conditions in the family
  8. 08

    Review of Systems

    • Only the systems discussed, with the findings actually stated
    • Skin rashes, alopecia, oral ulcers
    • Sicca symptoms, Raynaud phenomenon, eye symptoms
  9. 09

    Physical Examination

    • Vital signs and general appearance
    • Joint counts, synovitis, crepitus
    • Deformities in MCP, PIP, DIP, MTP joints
    • Skin examination: malar rash, tophi, psoriasis
  10. 10

    Laboratory & Imaging Results

    • Inflammatory markers: ESR, CRP
    • Autoantibodies: ANA with pattern, RF, anti-CCP, anti-dsDNA, anti-Sm
    • ANCA, HLA-B27, uric acid
    • Synovial fluid analysis
    • X-ray, ultrasound, or MRI findings and impression
  11. 11

    Assessment

    • The clinical impression the clinician stated
    • A differential, only where one was verbalized
    • A disease-activity score such as DAS28 or CDAI, only where stated
  12. 12

    Plan

    • Treatment and medication changes or tapers
    • Any glucocorticoid-sparing strategy
    • Monitoring labs, such as methotrexate monitoring
    • Additional testing and imaging
    • Follow-up interval and referrals

The format

One built-in format

  1. Rheumatology Note

    Rheumatology specialty visit note with strict evidence rules.

    12 sections

Questions from rheumatology clinics

Does it record the ANA pattern, not just positive or negative?
Yes. The Laboratory & Imaging Results section captures ANA with pattern, alongside RF, anti-CCP, anti-dsDNA and anti-Sm as autoantibodies on their own line.
Which other serology has a place in the format?
Inflammatory markers (ESR, CRP), ANCA, HLA-B27 and uric acid, and synovial fluid analysis. Anything not mentioned during the visit is left out rather than padded.
How is imaging documented?
X-ray, ultrasound or MRI findings and impression are captured as stated, with the report impression kept as written rather than paraphrased.
Can I adapt the format to my practice?
You can add formats of your own, and save your own copy of any built-in one. The built-in one already carries the rheumatology vocabulary.

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 rheumatology 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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