AI Medical Scribe for OB/GYN

Common documentation challenges in OB/GYN

OB/GYN practices handle one of the widest spectrums of visit types in medicine. A morning schedule might include a well-woman annual exam, two prenatal visits at different gestational stages, an acute gynecologic consult, and a contraceptive counseling session — each requiring a different documentation approach.

Patient education is a significant part of most OB/GYN encounters. Clinicians spend time discussing screening results, contraceptive options, pregnancy milestones, and postpartum recovery plans. These conversations matter clinically and often need to be documented, but capturing the substance of a 10-minute counseling discussion while staying present with the patient is difficult.

Prenatal care adds a longitudinal tracking requirement that most visit types do not. Each prenatal note builds on the last — gestational age advances, symptoms evolve, and the plan shifts as the pregnancy progresses. Maintaining consistency across dozens of prenatal visits for a single patient takes discipline and time.

Documentation of sensitive topics requires particular care. Reproductive health conversations involve personal decisions, and the clinical record needs to reflect what was discussed accurately without unnecessary detail. This balance is harder to strike when charting under time pressure.

Visit types Dictum supports

Dictum generates documentation drafts across the range of OB/GYN encounters. The output adapts to the content and structure of each visit rather than applying a single template to every appointment.

For prenatal visits, Dictum captures gestational context — age, interval symptoms, fetal movement — and organizes the note to reflect where the patient is in their pregnancy. For gynecologic encounters, the note structure shifts to match the clinical focus of that visit type.

How Dictum helps OB/GYN clinicians

A large part of OB/GYN documentation involves capturing what was discussed, not just what was examined. Patient education about screening options, birth plans, postpartum expectations, and contraceptive choices often takes up most of the visit — and that counseling needs to appear in the record. Dictum captures these discussions using the ambient AI scribe and maps the content to the appropriate note sections.

For prenatal care, Dictum structures each visit note with gestational context so the documentation reflects the progression of the pregnancy. Interval history, symptoms since the last visit, and plan changes are organized consistently across appointments, which reduces the effort of maintaining a coherent longitudinal record.

Sensitive topics are documented based on what the clinician and patient discussed. You review every note before it enters the medical record, which means you decide what level of detail is appropriate and how information is framed. Dictum provides the draft; the clinical judgment about what belongs in the chart remains yours.

With custom clinical templates, you can define separate documentation structures for obstetric and gynecologic visits. A prenatal template can include sections for gestational age, fetal heart tones, and fundal height, while a gynecologic template emphasizes the presenting complaint, examination findings, and plan.

Documentation outputs

Dictum generates several documentation types relevant to OB/GYN practice:

• SOAP notes — structured notes for gynecologic visits, prenatal encounters, and postpartum follow-ups. See AI SOAP note generation for details on how each section is populated.
• Prenatal visit notes — notes organized with gestational context, interval symptoms, and pregnancy-specific plan elements.
• After-visit summaries — patient-facing summaries in plain language covering what was discussed, next steps, and upcoming appointments. Particularly useful for prenatal care where patients benefit from written instructions between visits. See after-visit summaries.
• Referral letters — when referring to maternal-fetal medicine, reproductive endocrinology, or other specialists, Dictum drafts a letter summarizing the relevant history and reason for referral. See referral letters.

All outputs are plain text that copies into any EHR note field — Epic, Cerner, Athena, or whatever system your practice uses.

Example OB/GYN note structure

Below is an example of how Dictum structures a prenatal visit note. The clinician reviews and adjusts the draft before adding it to the medical record.

The specific content of each section is drawn from the encounter conversation. Dictum maps what was discussed to the appropriate SOAP category — the clinician then verifies accuracy, adds detail the AI could not infer, and finalizes the note.

Privacy and clinician review

OB/GYN documentation often involves sensitive health information. Clinicians should review all AI-generated notes for accuracy and appropriateness before adding them to the medical record. Dictum supports documentation workflows only and does not provide medical recommendations.

Every note Dictum generates is a draft. It does not enter any EHR automatically and does not leave the application unless you explicitly copy or export it. You control what is included in the final documentation, how sensitive topics are worded, and what level of detail is appropriate for each patient encounter.

Audio recordings are processed in real time and not retained on our servers after transcription. Generated notes are encrypted and stored in your Dictum account until you choose to export or delete them. Dictum is designed to meet HIPAA requirements for handling protected health information.

For details on available plans and usage, see Dictum pricing. For a broader look at how Dictum works across clinical specialties, visit the specialties overview.