AI Medical Scribe for Obstetrics & Gynecology

Obstetrics and gynecology presents unique documentation challenges that demand both speed and precision. From time-sensitive prenatal visits where every minute with the patient matters, to complex delivery documentation that must capture critical timelines and outcomes, to sensitive gynecologic conversations that require your full presence—OB/GYN practitioners face constant pressure to document thoroughly while maintaining the personal connection that defines quality care.

The traditional approach forces impossible choices: spend precious appointment time typing into the computer while your pregnant patient waits with questions, or stay late every night completing charts after long days that may have included emergency deliveries. Neither option serves you or your patients well.

OrbDoc’s voice-first AI medical scribe transforms this dynamic. Speak naturally during prenatal visits, procedures, and deliveries—OrbDoc captures every clinical detail, generates comprehensive documentation, and links evidence to support your medical decision-making and procedure coding. Your focus stays where it belongs: on the patient in front of you.

Prenatal Care Documentation

Prenatal visits require capturing multiple data points—vital signs, fundal height measurements, fetal heart tones, interval history, screening results, patient education—all within appointment slots that rarely feel long enough for the conversations your patients need.

With OrbDoc, prenatal documentation becomes effortless. As you measure fundal height, simply say “fundal height 28 centimeters, consistent with dates.” While listening to fetal heart tones, state “fetal heart rate 145, regular rhythm, good variability.” Discussing screening results, you might say “patient declining genetic screening after detailed counseling on risks and benefits, understands implications.”

OrbDoc captures these clinical details in real-time, automatically organizing information into the proper documentation structure. Interval history flows naturally as you ask about symptoms—any statement about decreased fetal movement, contractions, bleeding, or other concerns gets documented accurately without breaking eye contact or interrupting the conversation.

The platform understands OB-specific terminology and measurements. Whether you’re documenting Leopold maneuvers, discussing kick counts, reviewing glucose tolerance test results, or providing education about warning signs, OrbDoc translates your natural speech into precise clinical documentation.

Patient education documentation, often time-consuming yet essential, happens automatically. When you discuss nutrition, exercise, common pregnancy symptoms, or preparation for delivery, OrbDoc captures the education provided—critical for continuity of care and supporting the evaluation and management level of your visit.

For high-risk pregnancies requiring more detailed documentation, OrbDoc scales effortlessly. Chronic hypertension monitoring, gestational diabetes management, twin pregnancies, advanced maternal age considerations—all the additional complexity gets documented as thoroughly as routine prenatal care, simply by speaking naturally about your clinical assessment and plan.

Labor and Delivery Documentation

Delivery documentation must capture precise timelines, critical clinical findings, and rapid decision-making—all while you’re actively managing labor or performing delivery. The traditional approach of documenting hours after the fact leads to incomplete records and increases medical-legal risk.

OrbDoc enables real-time delivery documentation through voice. During active labor, you can state your findings: “8:45 PM, cervix 6 centimeters dilated, 90% effaced, minus 1 station, vertex presentation.” As labor progresses, updates flow naturally: “10:20 PM, complete dilation, patient feeling urge to push, epidural providing adequate pain relief.”

The delivery note itself becomes remarkably straightforward. As events unfold, speak the details: “spontaneous vaginal delivery of live male infant at 11:47 PM, Apgar 8 at one minute and 9 at five minutes, birthweight 3,450 grams, nuchal cord times one reduced without difficulty, active management of third stage, intact placenta delivered at 11:52 PM.”

OrbDoc automatically structures this information into a comprehensive delivery note, capturing the timeline, critical findings, any complications, and interventions performed. Second-degree laceration repair, shoulder dystocia management, postpartum hemorrhage interventions—whatever the clinical situation demands, documentation happens through your natural description of events.

For cesarean deliveries, the operative note can begin in the OR. Indication, consent, positioning, prep, draping, incision details, delivery specifics, placental findings, closure techniques—all captured by voice as you work, creating a detailed operative note that requires minimal editing later.

Postpartum documentation flows with equal ease. Fundal checks, lochia assessment, perineal examination, breastfeeding support, discharge planning—simply state your findings and recommendations as you provide care. OrbDoc ensures nothing gets missed in the documentation while you focus on the immediate clinical needs of mother and baby.

Women’s Health Practice Results

A four-physician OB/GYN group implemented voice-first documentation to address documentation burden threatening practice sustainability. Each physician spent 2-3 hours nightly completing charts, with deliveries requiring extensive late-night documentation.

Implementation began with prenatal visits where time pressure was most acute. Within two weeks, every physician reported improvements in both efficiency and patient interaction.

Results after six months:

• Reduced prenatal visit documentation time from 12 minutes to 3 minutes
• Decreased delivery note completion time from 45 minutes to 15 minutes
• Reduced after-hours charting substantially
• Improved patient satisfaction scores, particularly for physician attentiveness
• Added appointment capacity without extending hours
• Improved revenue through better documentation supporting appropriate E&M coding

The practice expanded documentation to gynecologic visits and procedures. Colposcopy, IUD placement, and endometrial biopsy procedures became faster and more thorough through voice documentation.

Delivery documentation showed dramatic improvement. Physicians document in real-time by voice during labor progress checks and delivery, completing notes shortly after delivering the placenta.

OB/GYN physicians describe improved work-life balance, better patient care, and improved practice financial health after implementation.

Gynecologic Exam and Procedures

Gynecologic care requires documenting sensitive examinations and procedures while maintaining patient comfort and dignity. Traditional documentation approaches force you to choose between thorough notes and patient-centered care.

OrbDoc enables you to maintain focus on your patient throughout gynecologic visits. During well-woman exams, findings flow naturally into documentation: “external genitalia normal, speculum exam shows healthy cervix, no discharge or lesions noted, bimanual exam reveals normal-sized anteverted uterus, no adnexal masses or tenderness.”

The platform understands gynecologic terminology and examination components. Whether documenting Pap smear collection, HPV testing, clinical breast exam, or contraceptive counseling, your natural description becomes structured documentation automatically.

For procedures, voice documentation proves particularly valuable. During colposcopy, you can narrate findings in real-time: “satisfactory examination, transformation zone fully visible, acetic acid application shows acetowhite area at 6 o’clock, biopsy taken, Monsel’s solution applied for hemostasis.” The procedure note practically writes itself.

IUD placement documentation becomes equally straightforward. “Informed consent obtained and documented, bimanual exam confirms uterine position, tenaculum placed at anterior lip of cervix, uterine sound measures 8 centimeters, IUD placed without difficulty, threads trimmed to 3 centimeters, patient tolerated procedure well.” Each step documented as you perform it, ensuring complete records without compromising sterile technique or patient interaction.

Endometrial biopsy, LEEP procedures, cryotherapy, Nexplanon insertion—whatever procedure you’re performing, documentation happens through natural speech. OrbDoc captures the indication, consent process, procedure steps, findings, and post-procedure instructions, creating comprehensive procedure notes that support appropriate coding and medical-legal protection.

Complex gynecologic visits involving multiple issues—abnormal bleeding, pelvic pain, sexual dysfunction, menopausal symptoms—often generate lengthy documentation requirements. OrbDoc handles this complexity effortlessly, organizing your discussion into appropriate documentation sections without requiring you to think about structure during the patient encounter.

ROI for OB/GYN Practices

The return on investment for OrbDoc in OB/GYN practices extends far beyond simple time savings, though those alone often justify the investment.

Time savings per visit are substantial and consistent. Prenatal visits that previously required 10-15 minutes of documentation now take 2-4 minutes of review and sign-off. Gynecologic visits show similar improvements. The cumulative effect over dozens of daily encounters transforms practice flow and physician well-being.

After-hours charting reduction delivers perhaps the most significant quality-of-life improvement. OB/GYN physicians frequently report 2-4 hours of nightly charting before implementation, particularly after days including deliveries. Post-implementation, most physicians complete documentation more efficiently, with delivery documentation taking substantially less time.

Patient satisfaction impact appears consistently in measured outcomes and anecdotal feedback. Patients notice when their physician maintains eye contact, listens without typing, and seems fully present during sensitive discussions. This improved interaction quality translates to higher satisfaction scores, better online reviews, and stronger patient retention.

Documentation quality improvements support both clinical care and revenue optimization. More thorough interval history, better capture of patient education and counseling, complete procedure documentation—all these factors support appropriate E&M coding and reduce audit risk. Practices report increases in evaluation and management revenue through better documentation of the care already being provided.

The platform’s evidence-linking capability provides particular value for procedures and complex decision-making. When documentation automatically links clinical findings to procedure indications, coding rationale, and medical decision-making support, audit defense becomes straightforward and compliance risk decreases significantly.

Practice capacity expansion represents another ROI dimension. Time saved on documentation can translate directly to additional appointment slots without extending hours. For practices at capacity, this creates revenue growth opportunity without requiring facility expansion or additional physicians.

Physician recruitment and retention increasingly depend on documentation efficiency. New graduates entering practice expect modern tools that minimize administrative burden. Established physicians considering practice changes rank documentation burden among their top concerns. OrbDoc becomes a competitive advantage in both attracting and retaining physician talent.

Financial impact becomes clear within initial implementation months, accounting for subscription costs and implementation time. Practices then continue realizing ongoing benefits across efficiency, revenue, satisfaction, and physician well-being metrics.

For OB/GYN practitioners facing relentless documentation pressure while trying to provide compassionate, thorough care across prenatal visits, deliveries, gynecologic exams, and procedures—OrbDoc offers a transformative solution. Voice-first documentation that captures every clinical detail, generates comprehensive charts, and returns your focus to the patient relationship that defines quality care.

The technology adapts to your workflow rather than forcing you to adapt to the technology. Whether you’re examining a patient, performing a procedure, or managing a delivery, documentation happens naturally through speech, creating thorough records without compromising the human connection at the heart of obstetrics and gynecology.