AI Scribe for ENT & Otolaryngology
Transcribe Health drafts your clinic notes, scope findings, and procedure reports while you work, so the head-and-neck detail is on the page before you move to the next room.
Photo: Usman Yousaf / Unsplash
ENT documentation, from clinic exam to post-op check
ENT is exam-heavy in a way most specialties are not. A single sinus or voice complaint pulls you through the ear, nose, and throat, often with a scope in hand, and each structure has its own findings and its own side. Otoscopy, anterior rhinoscopy, and a flexible laryngoscopy can all live in one visit, and the note has to keep the laterality straight for every one of them.
Much of the work happens right in the room. Cerumen removal under the microscope, nasal endoscopy, laryngoscopy, a biopsy: these are billable procedures done between the history and the plan, and the note has to record what was done, how, and what you saw. When charting slips to the end of the day, that detail is the first thing to blur.
Transcribe Health listens to the visit and drafts a note that keeps the exam findings, the scope description, and the procedure detail where they belong, with the correct side on each. You read it and sign. The pre-op assessment and the post-op check read the same way, so the record stays consistent from the first visit through recovery. Nothing is filed without you.
Documentation Challenges in ENT
- 1
Capturing a detailed head-and-neck exam that runs through otoscopy, anterior rhinoscopy, and flexible scope findings, each with its own set of terms and laterality
- 2
Switching between a clinic that moves fast and an OR schedule the same week, so notes get written from memory hours after the encounter
- 3
Documenting in-office procedures like flexible laryngoscopy, nasal endoscopy, and cerumen removal precisely enough that the CPT code holds up under review
How Transcribe Health Helps ENT
Scope Exam Documentation
Writes up what you describe on nasal endoscopy or flexible laryngoscopy: mucosa, secretions, mass or lesion, vocal fold mobility, and the side each finding is on.
In-Office Procedure Notes
Turns your narration during or after cerumen removal, a scope, or a biopsy into a procedure note with the detail the CPT code needs.
Clinic-to-OR Continuity
Drafts the clinic note the same day you see the patient, so the pre-op picture is clear when you take them to the OR and again at the post-op visit.
An ENT note, captured in real time
An abridged clinic visit for chronic rhinosinusitis with nasal endoscopy, drafted the way you would see it before signing.
44-year-old woman with a 5-month history of nasal congestion, facial pressure over the cheeks and forehead, and thick postnasal drainage. Reports reduced sense of smell and two courses of antibiotics this year with only partial relief. Denies fever, epistaxis, or vision changes. Currently using an intranasal steroid spray daily and saline rinses. Symptoms worse in the mornings.
Otoscopy: both tympanic membranes intact and mobile, no effusion. Anterior rhinoscopy: boggy, edematous turbinates bilaterally with clear-to-mucoid secretions. Flexible nasal endoscopy: mucopurulent drainage from the middle meatus on the right, edematous middle turbinate, no gross polyps or mass, septum midline. Oropharynx clear, no tonsillar exudate. Neck supple, no cervical lymphadenopathy.
1) Chronic rhinosinusitis without nasal polyps, endoscopic evidence of right-sided mucopurulent drainage from the middle meatus. 2) Hyposmia, likely related to mucosal inflammation. 3) Partial response to prior medical therapy.
Start a culture-directed antibiotic pending endoscopically guided culture from the middle meatus. Continue daily intranasal steroid and increase saline rinses to twice daily. Order a non-contrast CT of the sinuses to assess the ostiomeatal complex and rule out anatomic obstruction. If symptoms and CT findings persist after this course, discuss functional endoscopic sinus surgery. Return in 4 weeks to review the CT and response to treatment.
Illustrative example. Not a real patient encounter.
Built for ENT coding and your EMR
Notes capture the exam detail, the scope findings, and the procedure specifics that back up your E/M level and each in-office CPT code. That is the detail reviewers look for, and the first thing to slip when charting is rushed.
- 99204 / 99214New or established office visit, moderate complexity
- 31231Nasal endoscopy, diagnostic, unilateral or bilateral
- 31575Flexible laryngoscopy, diagnostic
- 69210Removal of impacted cerumen requiring instrumentation, unilateral
- 92567Tympanometry (impedance testing)
- 42804Biopsy of nasopharynx, visible lesion, simple
- J32.9Chronic sinusitis, unspecified
- J34.2Deviated nasal septum
- H66.90Otitis media, unspecified, unspecified ear
- H61.23Impacted cerumen, bilateral
- R49.0Dysphonia (hoarseness)
Fits the workflow you already have
Drafts drop into the major EMRs ENT groups run on: Epic, Oracle Health (Cerner), and athenahealth. You get whatever note type you are working in, a clinic visit, an in-office procedure note, or a post-op follow-up. It writes up the otoscopy, rhinoscopy, and scope findings you describe. It does not drive your endoscopy tower or read images; you make the call and it records it.
ENT AI scribe questions
Does it handle ENT exam and scope terminology?
Can it document in-office procedures, or only visits?
Does it keep laterality straight across the ear, nose, and throat?
How is patient information protected?
Will it help with coding for the procedures I do in clinic?
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