0%
Select Patient to Begin
Patient selection required
Needs Data
Select Patient
Search for an existing patient or add a new encounter for a walk-in.
AI Suggested Patients
Based on context
Encounter Details
Capture structured medical marijuana encounter details before documentation.
Encounter Information
Qualifying Condition & Eligibility
Mild
Severe
Cannabis History
Compliance & Registry
AI Pre-Summary
Qualification Status
Awaiting data...
Missing Items
- Encounter type
- Qualifying condition
- Provider selection
Risk Assessment
Low risk - Initial screening
Recommendation Complexity
Standard
AI Scribe
Real-time ambient documentation for a medical marijuana patient encounter.
Ready to Record
00:00
Voice Commands:
"Add qualifying condition chronic pain"
"Mark prior opioids ineffective"
"Document PTSD-related sleep disruption"
Live Transcript
0 wordsStart recording to generate transcript
00:00
Encounter started
Qualifying Condition
Awaiting transcript data...
Prior Therapies Failed
Awaiting transcript data...
Current Symptoms
Awaiting transcript data...
AI Documentation
Review and edit AI-generated clinical notes and certification recommendation content.
AI generating clinical notes...
SOAP Note
SUBJECTIVE
Confidence: 92%
Patient reports chronic lower back pain x 5 years, rated 7/10 severity. Pain interferes with sleep and mobility. Previous trials of NSAIDs and physical therapy provided minimal relief. Patient describes pain as "burning and stabbing," worse in evenings. Reports difficulty sleeping due to pain, averaging 4-5 hours nightly. No prior cannabis use. Patient seeks alternative to opioid medications previously prescribed but discontinued due to side effects.
OBJECTIVE
Confidence: 88%
Vitals stable. Physical exam reveals tenderness over L4-L5 paraspinal muscles, decreased range of motion in lumbar flexion. No neurological deficits observed. Patient ambulates with guarded gait. Review of prior imaging (MRI lumbar spine 2023) shows mild disc degeneration at L4-L5. Mental status exam: Alert and oriented x3, appropriate affect, no acute distress.
ASSESSMENT
Confidence: 95%
1. Chronic lower back pain (M54.5) - severe, refractory to conventional treatment
2. Insomnia secondary to chronic pain (G47.00)
3. Qualifies for medical cannabis certification under state guidelines for chronic pain refractory to standard treatment
2. Insomnia secondary to chronic pain (G47.00)
3. Qualifies for medical cannabis certification under state guidelines for chronic pain refractory to standard treatment
PLAN
Confidence: 90%
1. Recommend medical cannabis certification for chronic pain management
2. Start with low-dose evening edible (5mg THC) to address pain and sleep
3. Counsel on side effects, drug interactions, and impairment
4. Emphasize no driving or operating machinery while impaired
5. 30-day follow-up to assess efficacy and tolerance
6. Re-evaluate need for continued certification at 6 months
2. Start with low-dose evening edible (5mg THC) to address pain and sleep
3. Counsel on side effects, drug interactions, and impairment
4. Emphasize no driving or operating machinery while impaired
5. 30-day follow-up to assess efficacy and tolerance
6. Re-evaluate need for continued certification at 6 months
Medical Marijuana Recommendation Summary
Qualification Status
Eligible for Certification
Certification Term
6 Months (Initial)
Suggested Product Form
Low-dose Edible (Evening)
Follow-up Interval
30 Days
Physician Attestation Preview
"I attest that I have evaluated the patient and determined that the potential health benefits of the medical use of cannabis would likely outweigh the health risks, and that the patient qualifies for certification under state law for chronic pain refractory to conventional treatment."
Safety & Compliance Alerts
Identity Verification Pending
Return to Step 2 to confirm ID check completed
Coding Suggestions
M54.5
Low back pain (Primary)
Confidence: High
99214
E/M Level 4 - Detailed visit
Est. Reimbursement: $142
Review & Submit
Final review of the medical marijuana encounter before finalization.
Encounter Timeline
Patient selected: --
Encounter details entered
AI Scribe transcript generated (0 words)
AI Notes generated and reviewed
Compliance review pending
Encounter Summary
Patient
--
Provider
--
Visit Type
--
Qualifying Conditions
--
Compliance Validation
Required fields complete
Pass
Identity verification
Action Needed
Documentation Preview
Medical Cannabis Certification Encounter
Patient presents with chronic pain refractory to conventional treatment...
[Full SOAP note content from Step 4]
Export Options
Finalization
Current Status
Draft
Last saved: Never