How it works

Nurses write the way they talk. SecureScribe does the structuring.

Four documentation events, one shift, and a draft ready before handoff — without a nurse retyping anything into a form.

4Event types handled on day one
0Forms a nurse has to fill in
100%Drafts requiring nurse review
0Changes to your EHR
RxStep 01 · PRN

A nurse documents naturally

“Gave PO for agitation, patient reports relief within 20 minutes.”

Structured by SecureScribe

Extracted from the nurse’s own words
ReasonAgitation
EffectivenessRelief reported
Time19:42 · 20 min follow-up
Medication / doseNot documented!
Patient educationNot documented!

SecureScribe flags the gaps instead of guessing the medication or dose.

Step 02 · Refusal

A patient refuses medication

“Pt declined evening dose, stated he didn’t want to feel groggy for group tomorrow.”

Structured by SecureScribe

Extracted from the nurse’s own words
Medication refusedScheduled evening dose
Patient-stated reasonSedation concern
Education providedAwaiting entry!
Prescriber notifiedAwaiting entry!

Required elements are defined by your facility’s workflow, not by the model.

Step 03 · Behavioral

An escalation near shift change

“Pt escalated in dayroom after phone call, redirected verbally, no restraint, calm within 10 min.”

Structured by SecureScribe

Extracted from the nurse’s own words
AntecedentPhone call
BehaviorVerbal escalation, dayroom
InterventionVerbal redirection
Restraint / seclusionNone used
OutcomeCalm within 10 minutes

The nurse’s original wording stays attached to the structured record.

Step 04 · End of shift

The timeline becomes a draft

“Four documented events, one open gap, note drafted before handoff.”

Structured by SecureScribe

Extracted from the nurse’s own words
Events included4 documented
Required fields complete11 of 13!
Narrative draftReady for review
Posted to EHRBlocked until reviewed!

Nurse review required before posting. Nothing reaches the EHR unapproved.

Four stages, every shift

SecureScribe sits around the existing record. It does not replace your EHR.

STAGE 01

Document

Nurses capture events during the shift in their own clinical language.

STAGE 02

Validate

Required elements are checked and anything missing is flagged.

STAGE 03

Generate

A structured draft is assembled from the shift timeline, on-device.

STAGE 04

Review

The nurse verifies and approves before anything reaches the EHR.

See it on your unit.

A two-month pilot measures this against your own baseline.

Request a Pilot