Clinical Documentation
Document patient information with quick templates. Use voice or type. Memos auto-save locally.
Saved Memos
One tap saves every memo and appointment into a single backup file. Keep it somewhere safe — it's your copy if you switch phones or clear your browser. API keys are never included in backups.
Transcription Studio
Record a voice note or upload an audio file — Whisper transcribes it 100% on this device. No audio is uploaded anywhere. First use downloads the speech model once.
Tip
For live dictation while you talk, use the red VOICE button in the Notes tab. Use this studio for recordings and audio files — and for transcribing telehealth visit audio you recorded with consent.
Telehealth Visits
Video visits powered by Jitsi — free, no account or app needed for your patient. Each visit gets its own private room link you can copy and send.
New Appointment
Your Appointments
How it works
1. Create the appointment — a unique Jitsi room link is generated.
2. Tap Copy Link and text it to your patient. They tap it and join from any browser — no install, no account.
3. Tap Start Visit when it's time. Get consent, tick the box, and start live transcription so the conversation flows straight into your visit note.
4. End Visit & Save Note files it under Saved Memos in the Notes tab.
OASIS-E2 — Home Health Assessment
The complete guided OASIS-E2 (CMS, effective April 1, 2026) — every section, item, and response scale, researched from CMS sources. Choose the assessment reason and the form shows only the items that time point requires. BIMS, CAM, and PHQ scores calculate as you go. This is a documentation aid: you select and verify every response, and your agency EHR remains the official record. (M0064 SSN is intentionally not collected here — it stays in the agency record.)
Hospice — Painting the Picture
Hospice visit documentation built around one principle: paint the picture of the terminal patient. Every note documents the terminal diagnosis, pain, appetite, ADLs, appearance, sleep, cognition, dyspnea, edema, and education — with measurable observations (weights, mid-arm circumference, % of meals eaten, scale scores) and a comparison to the last visit, so decline is visible on paper. Includes the standardized scales hospice runs on — PPS, Karnofsky, FAST, and NYHA — and HOPE visit types.
Words that paint decline
Use precise descriptors — anorexic, cachectic, dyspneic at rest / with minimal exertion, frail — and follow each with “as evidenced by” plus what you actually saw. Avoid: stable, no change, eating well, no issues, no problems noted — those describe an absence of decline and can undermine eligibility.
HOPE (CMS, since Oct 1, 2025)
HOPE replaced the HIS for hospice quality reporting. Records: Admission, up to two HOPE Update Visits in the first 30 days, a Symptom Follow-Up Visit when symptom impact is moderate or severe, and Discharge. Submitted through iQIES. This form’s visit types match those records.
Recertification & the custodial trap
Recertification documentation needs measurable support data: decline indicators plus scale scores compared to admission and the last recert. Needing continued services is custodial — it is not, by itself, proof the patient is still terminal. If two notes disagree, explain the inconsistency in the note where it appears.
Behavioral Health — Psych Assessment
A complete behavioral-health toolkit: Mental Status Exam, the Columbia (C-SSRS) suicide risk screener with automatic risk pattern, PHQ-9 and GAD-7 with live totals, CIWA-Ar and COWS withdrawal scoring, the AIMS movement scale, and a structured safety plan. If a patient is in immediate danger, call 911; US Suicide & Crisis Lifeline: 988.
Wound Care Assessment
Full wound documentation — type, stage, measurements, drainage, odor, periwound skin — plus the Braden Scale for pressure-injury risk and the PUSH Tool for tracking healing week to week, both scored automatically.
MDS Companion — Nursing Home Key Items
The key items long-term-care nurses track between MDS assessments: ADL self-performance, continence, mood, pain, falls, behaviors, skin, weight change, swallowing, and medication classes. A companion for floor documentation — the facility MDS remains the official record.
Dementia Care Companion
Built for the patient and the caregiver: the Zarit caregiver burden short form with a live total, a 12-point home safety checklist, and an ABC behavior log (antecedent, behavior, consequence) for finding triggers and what works. Pairs with the FAST scale in the Hospice tab.
School Nurse Visit Log
Fast visit documentation for the health office: complaint, assessment, interventions, disposition, and parent notification — with one-line quick protocols for low blood sugar, anaphylaxis, asthma, seizures, and head injury. The student’s individual health plan always governs.
Dialysis Treatment Documentation
Pre- and post-treatment documentation: access assessment (bruit, thrill, infection checks), weights with automatic fluid-removal and interdialytic-gain math, blood pressures, symptoms during treatment, labs, and patient education.
Clinical Calculators
Tap a calculator to begin. High-risk calculations require dual verification.
Medication Dosing
Clinical Metrics
Critical Care Tools
Rapid assessments and ACLS protocols for emergency situations.
Glasgow Coma Scale
Burn Assessment (Rule of 9s)
H's & T's (Reversible Causes)
H's: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia
T's: Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary/coronary)
Epinephrine
VF/pVT
Asystole/PEA
1 mg IV/IO every 3-5 minutes during arrest
Amiodarone
VF/pVT
1st dose: 300 mg IV/IO bolus
2nd dose: 150 mg IV/IO
Lidocaine (Alternative)
VF/pVT
1st dose: 1-1.5 mg/kg IV/IO
2nd dose: 0.5-0.75 mg/kg
Quick References
Essential nursing resources and drug references.