AI Scribe for Internal Medicine & Hospitalists
Built for the split between hospitalist inpatient work and complex outpatient clinic. Full admission H&Ps, daily progress notes, discharge summaries with med reconciliation, and multi-comorbid follow-ups managing 8-15 active problems per visit. Real medications, real doses, accurate ICD-10.
Documentation for Every Internal Medicine Setting
The six note types that make up the bulk of an internist's week — inpatient, outpatient, and the transitions between them.
Hospitalist Admission (H&P)
Comprehensive H&P with 14-system ROS, full physical exam, differential, and admission orders. Bills 99221/99222/99223 by complexity.
Daily Inpatient Progress
Subsequent hospital care notes (99231/99232/99233) with overnight events, exam, problem-based assessment, and updated plan.
Outpatient Multi-Comorbid
Established complex follow-ups managing 8-15 active problems with medication titration and time-based billing support.
Discharge Planning
Discharge summary with reconciled meds, hospital course by problem, follow-up plan, and patient instructions.
Annual Wellness Visit
Medicare AWV (G0438 initial, G0439 subsequent) with HRA, cognitive screen, and prevention plan for the IM Medicare panel.
Pre-Operative Evaluation
Risk-stratified pre-op note with RCRI/Gupta scores, medication management, and surgical clearance language.
Built for the Real Complexity of IM
Six features that matter when a single visit involves T2DM, HFrEF, CKD, A-fib, COPD, and HLD
Hospitalist H&P Template
Full admission template with chief complaint, HPI, comprehensive ROS by 14 systems, complete physical exam, problem-based assessment with differential, and risk-stratified plan. Suggests 99221/99222/99223 by documented MDM.
Problem-Based Daily Progress
Each active problem gets its own subjective + objective + assessment + plan block. Carries forward overnight events, vitals trends, and pending studies. Suggests 99231/99232/99233 by stability.
Real Medications, Real Doses
Captures actual ordered doses — insulin drip 0.1 u/kg/hr, piperacillin-tazobactam 4.5 g IV q8h, vancomycin 1 g IV q12h with trough goal, metformin 1 g BID, lisinopril 20 mg daily — not generic placeholders.
Discharge Med Reconciliation
Compares admission med list to discharge orders, flags held/changed/new medications, and structures the discharge summary so the receiving PCP can see exactly what changed and why.
Critical Care Time Tracking
Captures time spent at the bedside on critical care (99291/99292) with documentation of high-acuity interventions, decisions, and discussions to defend the time.
Time-Based E/M Billing
For 2021 E/M outpatient visits, supports time-based selection of 99213/99214/99215 plus prolonged service codes (99417, G2212) when total visit time, including pre/post-encounter chart work, exceeds threshold.
A Saturday on the hospitalist service
Last reviewed by the PatientNotes Clinical Team — April 2026
Hospitalist medicine is documentation-intensive in ways outpatient care is not. A typical 12-hour shift covers 18-22 active patients on the rounding list, plus 4-7 new admissions from the ED, plus cross-cover calls overnight if you are on night shift. Every patient generates a daily progress note (99231/99232/99233) keyed to acuity. Every admission requires a comprehensive H&P (99221/99222/99223) with full ROS, full physical, problem-based assessment, and risk-stratified plan. Every discharge needs a summary with reconciled medications and follow-up. Without ambient capture, that is 4-6 hours of post-shift charting in front of an Epic or Cerner dock at 10pm.
PatientNotes was built differently for the hospitalist workflow. You start the recording when you walk into the room and stop when you walk out. The note draft is structured by problem, not by free-form narrative — so the DKA bullet, the sepsis bullet, the AKI bullet, and the troponin-bump bullet each get their own assessment-and-plan block. The medication list captures actual ordered doses (insulin drip 0.1 u/kg/hr, pip-tazo 4.5 g IV q8h, vancomycin trough goal 15-20) rather than generic placeholders. Critical care time (99291/99292) is captured as you describe interventions and decisions to the team or to the patient's family.
The discharge summary is where ambient AI shines hardest. Reconciling 14 admission medications against 19 discharge medications, flagging which were held, changed, or new, summarizing the hospital course by problem, including the pending blood cultures and the cardiology follow-up and the patient instructions in plain language — all of that used to be 25 minutes per discharge with a half-cold dinner waiting. With PatientNotes most internists draft a complete discharge summary in 3-4 minutes of editing on top of the AI output.
Sample AI-Generated Hospitalist H&P
A real admission for DKA + sepsis from CAP + AKI — the kind you see every other shift
HOSPITALIST ADMISSION H&P CHIEF COMPLAINT: "I can't stop throwing up and my breathing is bad." HPI: 54-year-old male with PMH of T2DM (last A1c 11.2% three months ago, non-adherent to insulin x 1 week per spouse), HTN, HLD, and 30 pack-year tobacco history presents to ED via EMS with 2 days of nausea, vomiting, abdominal pain, polyuria, polydipsia, and progressive dyspnea. Family states he stopped his insulin glargine 30 units nightly and metformin 1 g BID approximately 7 days ago after running out of refills. In ED: T 38.4 C, HR 126, BP 88/54, RR 28 and labored, SpO2 88% on room air improving to 94% on 4 L NC. POC glucose 612 mg/dL. ABG: pH 7.18, pCO2 22, HCO3 8, AG 28. Beta-hydroxybutyrate 6.2 mmol/L. Lactate 4.1. Cr 2.4 (baseline 1.0). WBC 18.4 with 14% bands. Procalcitonin 8.4. CXR: right lower lobe consolidation. REVIEW OF SYSTEMS: Constitutional: Fevers, fatigue, 4 kg weight loss in 1 week HEENT: Dry mucous membranes, no sore throat Cardiac: No chest pain, no orthopnea Pulmonary: Dyspnea, productive cough x 3 days, R-sided pleuritic pain GI: Nausea, vomiting x 2 days, diffuse abdominal pain, no diarrhea GU: Polyuria, no dysuria Skin: No rash, no foot ulcers Neuro: No focal deficits, oriented x 3 but slow to respond All other systems reviewed and negative. PMH: T2DM (dx 2014), HTN, HLD, OA knees, GERD PSH: Right knee arthroscopy 2018 Allergies: NKDA Home meds: Insulin glargine 30 u SC qHS, metformin 1 g PO BID, lisinopril 20 mg PO daily, atorvastatin 40 mg PO qHS, omeprazole 20 mg PO daily, ASA 81 mg PO daily — patient off all medications x 7 days SH: Lives with spouse, 30 pack-years (quit 6 months ago), occasional alcohol, no illicits FH: Father MI 58, mother T2DM PHYSICAL EXAM: Vitals on admission: T 38.4, HR 122, BP 92/58, RR 26, SpO2 94% on 4L General: Ill-appearing, lethargic, fruity breath odor HEENT: Dry mucous membranes, sunken eyes, no JVD Neck: Supple, no LAD CV: Tachycardic, regular, no m/r/g, weak peripheral pulses Pulm: Decreased breath sounds RLL with bronchial breathing, crackles RLL, no wheeze; using accessory muscles Abdomen: Soft, mild diffuse tenderness, no rebound, BS+ Extremities: No edema, capillary refill 3 sec, no pedal ulcers Skin: Warm, dry, no rash Neuro: Lethargic but arousable, oriented to self and place, follows commands, no focal deficits, normal reflexes DATA: - BMP: Na 132, K 5.6, Cl 96, HCO3 8, BUN 48, Cr 2.4, Glu 612 - Calculated AG: 28 (corrected for albumin 26) - ABG: 7.18 / 22 / 78 / 8 — high anion gap metabolic acidosis with partial respiratory compensation - Beta-hydroxybutyrate: 6.2 mmol/L - Lactate: 4.1 mmol/L - WBC 18.4 (14% bands), Hgb 14.2, Plt 312 - Troponin <0.03, BNP 88 - UA: 4+ glucose, 3+ ketones, no nitrites, 5-10 WBC - Blood cultures x2 pending; sputum culture pending - CXR: RLL consolidation, no effusion, no pneumothorax - EKG: Sinus tachycardia at 122, no acute ST changes - Repeat A1c: 13.4% ASSESSMENT: 54M with poorly controlled T2DM presenting with concurrent DKA, severe sepsis from community-acquired pneumonia, AKI on CKD, and likely septic shock physiology. High illness severity. PROBLEMS: 1. Diabetic ketoacidosis (E11.10) — high anion gap metabolic acidosis, beta-hydroxybutyrate 6.2, glucose 612. Insulin non-adherence x 1 week plus infectious trigger. 2. Severe sepsis from CAP, RLL (A41.9 + J18.9) — meets sepsis criteria with WBC 18.4 with bandemia, lactate 4.1, BP 88/54, RR 28, T 38.4. 3. Acute kidney injury (N17.9) — Cr 2.4 from baseline 1.0; volume depletion + sepsis-related. 4. Type 2 diabetes mellitus, uncontrolled (E11.65) — A1c 13.4%, off home medications x 1 week. 5. Tobacco use disorder, in remission (Z87.891) — quit 6 months. 6. Hypertension (I10) — currently hypotensive in setting of sepsis. PLAN: 1. DKA: Admit to ICU. NS bolus 30 mL/kg over first hour, then 250 mL/hr while rechecking BMP q2h. Insulin drip 0.1 u/kg/hr after K >3.5; do not bolus. Add D5 to fluids when glucose <250. Goal anion gap closure, then transition to subcutaneous regimen with overlap. 2. Severe sepsis / septic shock: Lactate 4.1 — meet sepsis bundle. Piperacillin-tazobactam 4.5 g IV q8h after blood cultures drawn. Add vancomycin 25 mg/kg IV load, then 15 mg/kg q12h, target trough 15-20 (MRSA coverage). Norepinephrine drip if MAP <65 after 30 mL/kg fluids. Repeat lactate q4h. 3. AKI: Avoid nephrotoxins, hold lisinopril and metformin, dose-adjust antibiotics by renal function, monitor UOP goal 0.5 mL/kg/hr. 4. T2DM: Insulin drip per DKA protocol, will resume basal-bolus when anion gap closes and patient eating; diabetic education on discharge. 5. Pneumonia: Above antibiotics, sputum culture, respiratory isolation pending viral panel including influenza/RSV/COVID, oxygen titrate to SpO2 >92%. 6. VTE prophylaxis: Heparin 5000 u SC q8h once stabilized. 7. GI: Famotidine for stress ulcer prophylaxis. 8. Code status: Full code, confirmed with patient and spouse. 9. Disposition: ICU; HM consult to follow once stabilized. 10. Family meeting scheduled. Time spent: 75 minutes for admission H&P, complexity high. CPT: 99223 (high MDM admission, comprehensive H&P) ICD-10: E11.10, A41.9, J18.9, N17.9, E11.65, I10, Z87.891
Common Internal Medicine ICD-10 Codes
Eight codes that show up across hospitalist admissions and outpatient IM follow-ups
E11.10Type 2 diabetes with ketoacidosis (DKA)A41.9Sepsis, unspecified organismJ18.9Pneumonia, unspecified organismN17.9Acute kidney injury, unspecifiedI50.23Acute on chronic systolic heart failureI48.0Paroxysmal atrial fibrillationI10Essential (primary) hypertensionE78.5Hyperlipidemia, unspecifiedFor inpatient encounters, CPT suggestions cover 99221/99222/99223 (admit), 99231/99232/99233 (subsequent), 99238/99239 (discharge), 99291/99292 (critical care). For outpatient: 99213/99214/99215 with 2021 E/M MDM or time-based selection plus 99417/G2212 for prolonged services.
Three internists, three settings
How locum hospitalists, outpatient IM groups, and academic teaching services use PatientNotes
Dr. David Wong, MD
Hospitalist, Sound Physicians, three rural hospitals in Idaho
David covers a 7-on-7-off block at three different rural hospitals — Meditech, Cerner, and Epic respectively. He needed a scribe that worked the same way regardless of which EHR he was on that week. PatientNotes generates the H&P or progress note in the same UI; he copy-pastes into whichever EHR is on screen. He typically does 18-22 admissions per shift; the time saved on H&Ps alone is 2-3 hours per shift, which means he leaves the hospital before 7pm.
Dr. Sarah Mendez, DO
Outpatient internist, 4-physician group, Atlanta GA
Sarah runs a complex outpatient panel — average 11 active problems per Medicare patient. She switched from Freed.ai because the multi-comorbid problem-based assessment was meaningfully better for the visits she actually does. The 2021 E/M time-based billing support helped her group justify 99215 visits that were previously down-coded to 99214 from incomplete documentation; the practice billing audit estimated $48,000/year in additional, defensible revenue.
Dr. Michael Patel, MD, FACP
Academic hospitalist, university medical center, Texas
Michael is an academic hospitalist who runs a teaching service of residents and medical students. He uses PatientNotes himself for his attending-of-record notes; the residents use it on their personal accounts (covered by the department) for their H&Ps. The attending oversight workflow — where Michael reviews and edits resident-drafted notes — is faster because the notes start in clean structured format. Resident chart-completion time dropped from a 26-hour median to under 6 hours.
Coming from Microsoft Dragon Medical One?
Hospitalists are among the heaviest Dragon users in medicine. Here is the honest comparison.
Dragon Medical One is the dominant dictation platform in hospital systems, owned by Microsoft via the Nuance acquisition. Many hospitalists have used Dragon for years to dictate H&Ps and discharge summaries directly into Epic or Cerner text fields. It is genuinely powerful, integrates deeply with hospital EHRs, and is a known quantity for IT departments. It is also a fundamentally different category of product: dictation versus ambient capture.
Dragon Medical One
- Type: Dictation, post-encounter
- Cost: $99-199/user/month + setup
- Hospital EHR integration: Deep (Epic, Cerner)
- H&P speed: 8-12 min dictation
- Best for: Heavy macro users, EHR-locked workflows
PatientNotes (Ambient)
- Type: Ambient, in-encounter
- Cost: $50/user/month, no setup
- Hospital EHR integration: Copy-paste, FHIR coming
- H&P speed: 2-3 min editing the AI draft
- Best for: Hospitalists who rotate across multiple EHRs
How to switch in three steps
- Run them in parallel for one full hospitalist block. Dictate every fifth admission with Dragon as you normally would and let PatientNotes capture the rest. Compare time-to-completion and note quality side-by-side.
- Convert your top three Dragon macros into PatientNotes templates. Common ones: normal pulm exam, normal cardiac exam, MRSA-coverage admission orders. Templates preserve the muscle memory.
- Cancel Dragon at contract renewal. Many hospital Dragon contracts are department-level — work with your service chief. Read the full breakdown on the Dragon vs PatientNotes comparison page.
PatientNotes vs Abridge vs Freed for Internal Medicine
Internal medicine splits between hospitalist and outpatient — different competitors dominate each. Here is the honest, side-by-side comparison.
For hospitalists, the typical alternative is Abridge — a well-funded ambient platform with deep Epic integration that is now standard at large academic medical centers (Kaiser, Sutter, Yale, Cleveland Clinic). For outpatient internists, the typical alternative is Freed.ai. Both are real competitors. Here is where each tool wins:
| Capability | Abridge | Freed.ai | PatientNotes |
|---|---|---|---|
| Price | $150-300/mo (enterprise) | $99/mo | $50/mo |
| Hospitalist H&P quality | Excellent | Limited | Excellent |
| Outpatient SOAP quality | Good | Excellent | Excellent |
| Epic in-workflow | Native | Copy-paste | Copy-paste, FHIR coming |
| Self-serve onboarding | No (enterprise sales) | Yes | Yes |
| Multi-EHR portability | Epic-centric | Yes | Yes |
| Discharge med reconciliation | Yes | No | Yes |
| Best for | Large Epic-only health systems | Solo outpatient internists | Hospitalist groups, IM clinics, locums |
Read the full comparisons at PatientNotes vs Abridge and PatientNotes vs Freed.
Internal Medicine AI Scribe — FAQ
Reviewed by the PatientNotes Clinical Team, April 2026
Does PatientNotes work for internal medicine?
Yes. Internal medicine is one of our largest user groups, split roughly 60/40 between outpatient internists and hospitalists. The AI handles full hospitalist H&Ps with comprehensive ROS and 10-system physical exam, daily progress notes (99231-99233), discharge summaries with reconciled medications and follow-up plan, and outpatient multi-comorbid follow-ups managing 8-15 active problems per visit. Time-based billing for prolonged services (99417, G2212) is supported.
How much does an AI scribe cost for internal medicine?
PatientNotes is $50 per user per month. Abridge typically prices through hospital enterprise contracts at $150-300/user/month for the inpatient product, Freed.ai is $99/month for outpatient, and Microsoft Dragon Medical One is $99-199/month plus implementation. For a hospitalist group of 12, PatientNotes is roughly $14,400/year against Abridge enterprise pricing of $30,000-50,000/year.
Is Abridge better than PatientNotes for hospitalists?
Abridge has a real Epic in-workflow integration that makes it the strongest choice for hospital systems already standardized on Epic with the IT capacity to deploy enterprise contracts. PatientNotes is the better choice for community hospitalist groups, hospitalist staffing companies (Sound, TeamHealth, Hospital Internists), small community hospitals, and any setting where deployment needs to be self-serve rather than 6-month enterprise IT projects. The H&P and progress note quality is comparable; PatientNotes is roughly 1/3 the cost.
Is Freed.ai better than PatientNotes for outpatient internal medicine?
Freed.ai produces solid outpatient SOAP notes for low-complexity visits. For internal medicine specifically — where a typical follow-up might involve T2DM, HFrEF (EF 35%), CKD stage 3a, A-fib on Eliquis, COPD, and HLD all in one visit — PatientNotes structures the assessment by problem, carries the full medication list including dose adjustments, and supports time-based billing better. Freed is fine for the 99213 visits; PatientNotes handles the 99214/99215 multi-comorbid complexity that defines real IM clinic.
Can hospitalist H&Ps and discharge summaries be auto-generated?
Yes. The hospitalist H&P template captures the full 14-system ROS, comprehensive physical exam, problem-based assessment with differential, and risk-stratified plan. Discharge summaries reconcile admission medications against discharge medications (with held vs continued vs changed flags), summarize the hospital course by problem, and include follow-up appointments, pending labs, and condition-specific patient instructions in plain language.
Does PatientNotes integrate with Epic or Cerner for hospitalists?
PatientNotes is EHR-agnostic. The structured note generates in PatientNotes and copies into Epic, Cerner, Meditech, or any EHR encounter (4-6 seconds per note). FHIR-based write-back is in development for Epic. We deliberately built copy-paste-first because hospitalist groups frequently rotate across multiple hospital systems with different EHRs in the same week.
Will it help me bill internal medicine CPT codes correctly?
Yes. For inpatient: suggests 99221/99222/99223 for admissions based on documented MDM and time, 99231/99232/99233 for daily progress, 99238/99239 for discharge, and 99291/99292 for critical care time. For outpatient: 99213/99214/99215 with 2021 E/M time-based or MDM-based selection, plus prolonged service codes (99417, G2212) when total visit time exceeds the threshold.
Is PatientNotes HIPAA compliant for hospital settings?
Yes. PatientNotes is HIPAA compliant, signs a BAA, encrypts audio and notes (TLS 1.3 in transit, AES-256 at rest), and is hosted in SOC 2 compliant US-based infrastructure. We support hospital-required data residency and retention policies, and audio is auto-deleted within 30 days of note generation by default. The platform is suitable for both employed hospitalists and locum/contractor physicians who need a portable scribe across hospital sites.
More resources for internists:
Document Hospitalist H&Ps in Three Minutes
For hospitalists, IM groups, and academic services. $50/user/month, no enterprise contract, 7-day free trial.
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