0%
Needs Data
Select a patient to begin
Draft
Select Patient
Search for an existing patient or add a new encounter for a walk-in.
AI Suggested Patients
Based on context
Encounter Details
Capture structured medical marijuana encounter details before documentation.
Encounter Information
Qualifying Condition & Eligibility
Mild
7
Severe
Cannabis History
Compliance & Registry
Supporting Documents
AI Pre-Summary
Probable Qualification
Select conditions to assess
Missing Compliance Items
- Residency verification
- Consent forms
Recommendation Complexity
Risk Warnings
None identified
AI Scribe
Real-time ambient documentation for a medical marijuana patient encounter.
Ready
00:00
Voice Command Suggestions:
"Add chronic pain"
"Mark opioids ineffective"
"Document PTSD sleep issues"
"Add impairment counseling"
Live Transcript
0 wordsRecording not started. Click "Start Recording" or "Simulate Conversation" to begin.
AI Documentation
Review and edit AI-generated clinical notes and certification recommendation content.
Documentation Quality Score
92%Subjective
95%
Objective
88%
Assessment
94%
Plan
90%
Compliance
96%
Recommendation
91%
SOAP Note
S
Subjective
94% confidence
Patient reports chronic lower back pain rated 7/10, affecting sleep and mobility. Describes pain as "sharp and burning" radiating to left leg. Reports previous use of NSAIDs and physical therapy with insufficient relief. States concern about opioid dependence. Also reports PTSD-related insomnia with nightmares occurring 3-4 times weekly.
O
Objective
88% confidence
Physical exam reveals tenderness over L4-L5 paraspinal muscles. Straight leg raise test positive on left at 45 degrees. No motor deficits observed. Patient appears alert and oriented. Mood appears anxious. Vitals stable. Reviewed medical records indicating failed trials of gabapentin and meloxicam.
A
Assessment
96% confidence
1. Chronic lower back pain with radiculopathy, moderate-severe, refractory to conventional treatment.
2. PTSD with insomnia and nightmare disorder.
3. Candidate for medical cannabis certification based on qualifying conditions per state regulations.
4. Risk assessment: Low-moderate for misuse, no contraindications identified.
2. PTSD with insomnia and nightmare disorder.
3. Candidate for medical cannabis certification based on qualifying conditions per state regulations.
4. Risk assessment: Low-moderate for misuse, no contraindications identified.
P
Plan
90% confidence
1. Recommend medical cannabis certification for 12 months.
2. Initial dosing: Low-dose evening edible (5-10mg THC) for pain and sleep.
3. CBD-dominant tincture for daytime anxiety management.
4. Counseling provided on impairment, driving restrictions, and proper storage.
5. Follow-up in 30 days to assess tolerance and efficacy.
6. Registry application submitted today.
2. Initial dosing: Low-dose evening edible (5-10mg THC) for pain and sleep.
3. CBD-dominant tincture for daytime anxiety management.
4. Counseling provided on impairment, driving restrictions, and proper storage.
5. Follow-up in 30 days to assess tolerance and efficacy.
6. Registry application submitted today.
Medical Marijuana Recommendation Summary
Qualification Status
Eligible for Certification
Recommendation Type
Initial Certification
Suggested Certification Term
12 Months
Suggested Product Forms
Edible, Tincture
Cannabinoid Approach
Balanced THC/CBD for evening; CBD-dominant for day
Follow-up Interval
30 Days
Physician Attestation
"I certify that I have assessed the patient's medical history, reviewed prior treatments, and believe the potential benefits of medical cannabis outweigh the risks for this patient. I have provided counseling on safe use, side effects, and legal restrictions."
Safety & Compliance Alerts
Registry ID missing
Psychiatric history noted - monitor mood
Coding Suggestions
M54.5
ICD-10
Low back pain
Confidence: 96%
F43.10
ICD-10
Post-traumatic stress disorder
Confidence: 94%
99214
CPT
Office visit, Level 4
Est. Reimbursement: $180
Recommendation Helper
Review & Finalize
Review all encounter details, documentation, and submit for certification.
Pre-Submission Validation
Ready to SubmitPatient Selected
James Wilson
Qualifying Conditions
Chronic Pain, PTSD
SOAP Documentation
Quality Score: 92%
Registry Submission
Ready for automatic submission
Documentation Summary
Encounter Type:
Initial Certification
Provider:
Dr. Sarah Chen, MD
Visit Mode:
In Person
Duration:
30 minutes
Qualifying Conditions & Severity
Chronic Pain (7/10)
PTSD (Moderate)
Prior Treatment Failures
NSAIDs, Physical Therapy, Opioids
Cannabis Recommendation
Duration: 12 months
Product Forms: Edible, Tincture
Approach: Balanced THC/CBD evening; CBD-dominant daytime
Compliance Verification
By submitting, you certify that you have reviewed all documentation, verified patient eligibility, and comply with all state medical marijuana regulations.
Final Actions
Registry Submission Options
Est. Processing Time:
2-3 minutes
Registry Status:
Ready
Documents Generated
SOAP Note
Certification Letter
Registry Form
Encounter Bill