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AI Scribe for Gastroenterology

Transcribe Health drafts your clinic and endoscopy notes while you work, so the GI detail is on the page before you move to the next room or the next case.

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GI documentation, from clinic to the endoscopy suite

Gastroenterology splits between two settings that produce very different notes. In clinic there are new consults and follow-ups for reflux, abdominal pain, altered bowel habits, IBD, and liver disease, where the symptom history, exam, prior scopes, pathology, and current medications all have to land in one note. In the endoscopy suite there are colonoscopies and upper endoscopies that need a structured report precise enough for pathology correlation, the next surveillance interval, and billing.

The detail is unforgiving. A colonoscopy report is expected to state prep quality on a scale like Boston, whether the cecum was reached, and for every polyp its location, size, morphology, and how it came out. An IBD follow-up can touch stool frequency, CRP and fecal calprotectin, current biologic and its dose, and the plan if the patient is losing response. Written by hand that means typing between cases or dictating after the list is done.

Transcribe Health listens to the clinic visit, or to your narration after a scope, and drafts a note that puts the GI detail where it belongs: findings, polyp descriptions, drug names and doses, lab values, and the reasoning behind your plan. You read it and sign. Nothing is filed without you.

Documentation Challenges in Gastroenterology

1
Splitting your day between clinic visits and the endoscopy suite, where each setting produces a different kind of note and neither can wait until the evening to write
2
Documenting colonoscopy and EGD findings with the specifics that pathology, follow-up intervals, and billing depend on: prep quality, cecal intubation, polyp count, size, morphology, and removal method
3
Tracking chronic disease over years, from IBD flares and biologic dosing to cirrhosis surveillance and its complications, with the exact labs and drug histories that decisions rest on

How Transcribe Health Helps Gastroenterology

Endoscopy Procedure Reports

Turns your post-procedure narration into a structured colonoscopy or EGD report: prep, extent of exam, findings, polyps removed, and the recommended surveillance interval.

Clinic Visit Notes

Drafts new-consult and follow-up notes from the visit, including the symptom history, exam, and medication plan you cover with the patient.

Chronic Disease Tracking

Records IBD activity, biologic and immunomodulator dosing, liver disease staging, and the labs behind each decision, without you retyping the history at every visit.

A GI note, captured in real time

An abridged Crohn's follow-up, drafted the way you would see it before signing.

Follow-up · Crohn's disease on maintenance infliximab

Subjective

34-year-old woman with ileocolonic Crohn's disease, seen for routine follow-up on maintenance infliximab. Reports one to two formed stools daily, no blood, no nocturnal symptoms, and no abdominal pain. No fevers, joint pain, or new skin lesions. Last infusion three weeks ago, tolerated well. Adherent to therapy. No recent antibiotics or NSAID use.

Objective

Afebrile, BP 116/70, HR 72. Abdomen soft, non-tender, no palpable mass, normal bowel sounds. No perianal disease on exam. Labs today: CRP 3 mg/L, fecal calprotectin 84 mcg/g, hemoglobin 13.1, albumin 4.2. Infliximab trough from last visit 6.2 mcg/mL, antibodies negative.

Assessment

1) Ileocolonic Crohn's disease, in clinical and biochemical remission on infliximab 5 mg/kg every 8 weeks, with a therapeutic trough. 2) No current evidence of active inflammation. 3) Due for colonoscopy surveillance given more than 8 years of colonic disease.

Plan

Continue infliximab 5 mg/kg every 8 weeks at current dosing. Repeat fecal calprotectin in 3 months. Schedule surveillance colonoscopy with chromoendoscopy for dysplasia given long-standing colonic Crohn's. Continue vitamin D supplementation. Confirm she is up to date on age-appropriate vaccinations before any dose escalation. Return in 3 months, sooner if symptoms recur.

Illustrative example. Not a real patient encounter.

Built for GI coding and your EMR

Notes capture what you found and did during a scope and the data and risk behind a clinic visit, the detail that sets the polypectomy code apart from a diagnostic colonoscopy and backs up your E/M level. That is the first thing to slip when charting is rushed between cases.

CPT

45378Colonoscopy, diagnostic, with or without collection of specimen
45380Colonoscopy with biopsy, single or multiple
45385Colonoscopy with removal of lesion by snare technique
43239Upper GI endoscopy (EGD) with biopsy, single or multiple
99204 / 99205New-patient consult, moderate to high complexity
99214 / 99215Established-patient follow-up, moderate to high complexity

ICD-10

K21.9Gastro-esophageal reflux disease without esophagitis
K50.90Crohn's disease, unspecified, without complications
K51.90Ulcerative colitis, unspecified, without complications
K57.30Diverticulosis of large intestine without perforation or abscess, without bleeding
K76.0Fatty (change of) liver, not elsewhere classified

Fits the workflow you already have

Drafts drop into the systems GI groups run on: Epic, Oracle Health (Cerner), and athenahealth for clinic notes, and the endoscopy reporting tools many practices use for procedures, such as Provation and gGastro. You get whatever note type you are working in, a clinic consult, a follow-up, or an endoscopy report. It writes up the findings, polyp descriptions, and plan you dictate. It does not generate the procedure images or replace your endowriter's structured fields; you make the call and it records it. Where a practice keeps its endoscopy reporting locked to one dedicated system, we draft the narrative and you paste it in.

Clinical Workflows

AI Medical Scribe for Gastroenterology

GI documentation spans clinic visits, endoscopy reports, IBD management, and hepatology. Here's how AI scribes handle the breadth of gastroenterology documentation.

Gastroenterology AI scribe questions

Does it understand GI terminology and drug names?

Yes. It captures agents like infliximab, vedolizumab, ustekinumab, mesalamine, and rifaximin, and details like Boston prep score, cecal intubation, polyp morphology by the Paris classification, and fecal calprotectin values, with correct spelling and dosing rather than phonetic guesses.

Can it document endoscopy, or only clinic visits?

Both. In clinic it drafts consult and follow-up notes from the visit. After a colonoscopy or EGD it structures a procedure report from your narration, covering prep, extent of exam, findings, and any polyps removed.

Will it help with coding and audit defensibility?

It surfaces the detail that decides the code: whether a lesion was biopsied or snared, how many polyps came out and by what method, and the data and risk that support your E/M level. In practice that reduces both under-coding and audit exposure.

How is patient information protected?

All data is encrypted in transit and at rest, handled under a Business Associate Agreement available on every plan, and covered by HIPAA for US practices and PHIPA and PIPEDA for Canadian practices.

Does it connect to our EMR and endoscopy reporting system?

Structured notes drop into major EMRs including Epic, Oracle Health, and athenahealth. For endoscopy it works with the reporting tools GI practices use, including Provation and gGastro. Where a system does not accept an external draft, you get a clean narrative to paste into the report.

HIPAA Compliant

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