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Recording

SOAP

Billing + summary

Saved + audit

Live transcript

Transcript captured

01:31

Doctor: Good morning Mr. Hayes, what brings you in today?
Patient: Morning doc. I've been having this pressure in my chest for about a week now. Comes on when I climb stairs, goes away after I sit down for a few minutes.
Doctor: Any pain radiating to your arm, jaw, or back?
Patient: A little bit into my left shoulder, yeah. Not the jaw though.
Doctor: Shortness of breath? Sweating?
Patient: Some shortness of breath when it happens. No sweating.
Doctor: Any history of heart problems, high blood pressure, or diabetes?
Patient: My dad had a heart attack at 60. I've got high blood pressure, on lisinopril 20 milligrams. Cholesterol was a little high last year.
Doctor: Smoker?
Patient: Quit five years ago. Smoked about a pack a day for 20 years before that.
Doctor: Okay. Let me take a listen. Blood pressure today is 148 over 92, heart rate 78, regular. Heart sounds normal, no murmurs. Lungs are clear.
Doctor: Given your symptoms and risk factors, I'm concerned about angina. I want to get an EKG today, send you for a stress test this week, and order a lipid panel and basic labs. I'm also going to start you on aspirin 81 milligrams daily and a statin. If the chest pain comes on at rest or doesn't go away in a few minutes, go straight to the ER.
Patient: Understood, doc.

Live copilot

Chest pain mentioned — consider ACS workup (ECG, troponin) and rule out PE.
Confirm drug allergies before prescribing.
Check foot exam, retinal screening, BP, and lipid panel.

Time saved

14 min

Reimbursement

$180

Insights

SOAP note

Subjective

54-year-old male reports intermittent chest pressure for about 1 week.
Pain occurs with exertion, especially climbing stairs, and improves after sitting for a few minutes.
Radiation to left shoulder. Associated shortness of breath. No diaphoresis reported.
Risk factors: hypertension on lisinopril 20 mg, hyperlipidemia history, former smoker, family history of MI in father at age 60.

Objective

BP 148/92, HR 78 regular.
Cardiac exam: normal heart sounds, no murmurs.
Lungs clear to auscultation.

Assessment

Exertional chest pain concerning for stable angina; ACS risk requires evaluation.
Hypertension, above goal today.
Hyperlipidemia history.
Former tobacco use with family history of CAD.

Plan

Obtain EKG today.
Order stress test this week.
Order lipid panel and basic labs.
Start aspirin 81 mg daily if no contraindication.
Start statin therapy.
ER precautions: chest pain at rest, pain that does not resolve quickly, worsening shortness of breath, diaphoresis, syncope, or radiation to jaw/arm/back.

ICD-10 + CPT billing

ICD-10 Codes

R07.9 — Chest pain, unspecified
I10 — Essential hypertension
E78.5 — Hyperlipidemia, unspecified
Z87.891 — Personal history of nicotine dependence
Z82.49 — Family history of ischemic heart disease

CPT Codes

99214 — Established patient office visit, moderate medical decision making
93000 — Electrocardiogram, routine ECG with interpretation and report
80061 — Lipid panel
80053 — Comprehensive metabolic panel

Patient summary

What we talked about

You have chest pressure that happens when you are active and gets better when you rest. You also noticed some shortness of breath.

What I think is going on

Your symptoms may be coming from your heart, so we are checking this carefully.

What we're going to do

We will do an EKG today, order a stress test, check blood work, and start medicines to lower heart risk if safe for you.

When to call back

Go to the ER right away if chest pain happens at rest, does not go away after a few minutes, gets worse, or comes with sweating, fainting, or severe shortness of breath.

SOAP approvedBilling approvedSummary approvedAudit logged

Audit log

HIPAA-grade activity trail

Every AI generation and clinician approval is recorded. Audio is never stored.

9 events

04:45:45 PMvisit.startedby Dr. Aiden Park
New encounter opened for Mr. Hayes
04:46:45 PMtranscript.capturedby Scribely AI
Live transcript completed (audio not stored)
04:47:45 PMsoap.generatedby Scribely AI
SOAP note drafted from transcript
04:48:45 PMbilling.generatedby Scribely AI
ICD-10 + CPT codes proposed
04:48:45 PMsummary.generatedby Scribely AI
Patient summary drafted (6th-grade reading level)
04:49:45 PMsoap.approvedby Dr. Aiden Park
Clinician approved SOAP note
04:49:45 PMbilling.approvedby Dr. Aiden Park
Clinician approved billing codes
04:50:45 PMsummary.approvedby Dr. Aiden Park
Clinician approved patient summary
04:51:45 PMchart.savedby Scribely AI
Encounter sealed to chart · HIPAA audit recorded