OneStep Scribe

OneStep ScribeBeta AI Psychiatric Scribe - OneStep Clinic

Auto-logout in 10 minutes due to inactivity. Click anywhere to stay signed in.

✓ Added to note

E

Psych Eval

New Patient

P

Progress

Follow-up

S

SOAP

Progress format

0 pts

0 selected

No past notes yet.
Notes save automatically after generation.

?

👤 Start Visit

Full Name *

DOB

Allergies

Visit Type

Paste Transcript

Paste a transcript with speaker labels. Format: [Clinician]: text or Speaker 1: text

P Patient Progress

>>>

00:00

Ready

ReadyRecordingTranscribingNote

Waiting... Ready - Speaker A:

Ready to record

Tap to record

00:00

Start Visit begins the recording visit

Clinical Assistance Panel

Measures

Session Notes

Notepad 0

Clinical Tools

CPT

Patient

My Templates

OneStep Scribe

Provider notepad

13

PIN

scratchpad only

0

Notepad

CPT Billing

99214

99204

90792

90833

99214
+90833

99204
+90833

Patient

?

Patient

VisitTranscript

?

Patient

VisitTranscript

Live TranscriptPsych Eval

Ready Dictation

Listening...
transcript appears as you speak

Ready

Sections

Record the session then click
Generate Note

Clinical Assistant

Clinical Assistant

DSM-5TR Criteria

MDD F32v

5+ symptoms x 2 weeks; must include depressed mood or anhedonia

Depressed mood most of the day, nearly every day Markedly diminished interest or pleasure in activities Significant weight loss/gain or appetite change Insomnia or hypersomnia nearly every day Psychomotor agitation or retardation (observable) Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive guilt Diminished ability to think or concentrate Recurrent thoughts of death or suicidal ideation

PDD F34.1v

Depressed mood more days than not >=2 years + 2 symptoms

Depressed mood most of day, more days than not, >=2 years Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness Never symptom-free >2 months during 2-year period

Bipolar I F31v

Manic episode >=1 week; 3+ symptoms (4 if mood only irritable)

Abnormally elevated, expansive, or irritable mood + increased energy Inflated self-esteem or grandiosity Decreased need for sleep (feels rested after ~3 hours) More talkative than usual or pressured speech Flight of ideas or racing thoughts Distractibility Increased goal-directed activity or psychomotor agitation Excessive involvement in high-risk activities Severe enough to cause marked impairment or hospitalization

Bipolar II F31.81v

Hypomanic episode >=4 days + lifetime MDE; never full manic episode

Elevated/expansive/irritable mood + increased energy >=4 days Inflated self-esteem or grandiosity Decreased need for sleep Pressured speech Racing thoughts or flight of ideas Distractibility Increased goal-directed activity or agitation Excessive high-risk activities Current or past Major Depressive Episode NOT severe enough to require hospitalization

GAD F41.1v

Excessive worry more days than not >=6 months + 3 symptoms

Excessive anxiety and worry about multiple events >=6 months Difficulty controlling the worry Restlessness or feeling keyed up/on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance

Panic Disorder F41.0v

Recurrent unexpected attacks + >=1 month persistent concern

Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Shortness of breath or smothering Feelings of choking Chest pain or discomfort Nausea or abdominal distress Dizziness, unsteadiness, or faintness Chills or heat sensations Paresthesias (numbness or tingling) Derealization or depersonalization Fear of losing control or "going crazy" Fear of dying >=1 month persistent worry or behavioral change after attack

Social Anxiety F40.10v

Marked fear of social situations with scrutiny >=6 months

Marked fear of social situations with possible scrutiny Fears humiliation or embarrassment in social situations Social situations almost always provoke fear or anxiety Social situations avoided or endured with intense fear Fear out of proportion to actual threat Persistent >=6 months Causes significant distress or functional impairment

PTSD F43.10v

Trauma exposure + 1+ B + 1+ C + 2+ D + 2+ E; duration >1 month

A. Exposure to actual/threatened death, injury, or sexual violence B. Intrusion: Recurrent involuntary distressing memories B. Intrusion: Recurrent distressing dreams B. Intrusion: Dissociative reactions (flashbacks) B. Intrusion: Intense distress at trauma cues B. Intrusion: Physiological reactions to trauma reminders C. Avoidance: Distressing memories/thoughts/feelings C. Avoidance: External reminders of the event D. Negative cognitions: Inability to remember key aspects D. Negative cognitions: Persistent exaggerated negative beliefs D. Negative cognitions: Distorted self/other blame D. Negative cognitions: Persistent negative emotional state D. Negative cognitions: Diminished interest in activities D. Negative cognitions: Detachment from others D. Negative cognitions: Inability to experience positive emotions E. Arousal: Irritable behavior and angry outbursts E. Arousal: Reckless or self-destructive behavior E. Arousal: Hypervigilance E. Arousal: Exaggerated startle response E. Arousal: Problems with concentration E. Arousal: Sleep disturbance

ADHD F90v

6+ inattention OR 6+ hyperactivity symptoms; onset before age 12; 2+ settings

Inattention: Fails to give close attention / makes careless mistakes Inattention: Difficulty sustaining attention Inattention: Does not seem to listen when spoken to directly Inattention: Does not follow through; fails to finish tasks Inattention: Difficulty organizing tasks Inattention: Avoids tasks requiring sustained mental effort Inattention: Often loses things necessary for tasks Inattention: Easily distracted by extraneous stimuli Inattention: Forgetful in daily activities Hyperactivity: Fidgets or squirms in seat Hyperactivity: Leaves seat when expected to remain seated Hyperactivity: Runs/climbs in inappropriate situations Hyperactivity: Unable to engage in leisure activities quietly Hyperactivity: "On the go," driven by a motor Hyperactivity: Talks excessively Impulsivity: Blurts out answers before question completed Impulsivity: Difficulty waiting their turn Impulsivity: Interrupts or intrudes on others

Schizophrenia F20.9v

2+ symptoms >=1 month; continuous signs >=6 months; >=1 must be delusions/hallucinations/disorganized speech

Delusions Hallucinations Disorganized speech (derailment or incoherence) Grossly disorganized or catatonic behavior Negative symptoms (diminished expression or avolition) Markedly decreased functioning in work, relationships, or self-care Continuous signs >=6 months (>=1 month active-phase symptoms)

BPD F60.3v

5+ of 9 criteria; pervasive pattern beginning by early adulthood

Frantic efforts to avoid real or imagined abandonment Unstable/intense relationships (idealization and devaluation) Identity disturbance: persistently unstable self-image Impulsivity in >=2 self-damaging areas Recurrent suicidal behavior, gestures, or self-mutilation Affective instability: marked mood reactivity Chronic feelings of emptiness Inappropriate, intense anger or difficulty controlling anger Transient stress-related paranoid ideation or dissociation

OCD F42.2v

Obsessions and/or compulsions; time-consuming (>1 hr/day) or causing significant distress

Obsessions: Recurrent intrusive unwanted thoughts/urges/images causing anxiety Obsessions: Attempts to ignore, suppress, or neutralize these thoughts Compulsions: Repetitive behaviors or mental acts Compulsions: Aimed at reducing anxiety; excessive or not realistically connected Time-consuming (>1 hr/day) or causes significant distress/impairment

ASD F84.0v

All 3 social criteria + 2+ restricted/repetitive; present in early development

Social: Deficits in social-emotional reciprocity Social: Deficits in nonverbal communicative behaviors Social: Deficits in developing/maintaining relationships Restricted/repetitive: Stereotyped or repetitive movements or speech Restricted/repetitive: Insistence on sameness, inflexible routines Restricted/repetitive: Highly restricted, fixated interests Restricted/repetitive: Hyper- or hyporeactivity to sensory input Symptoms present in early developmental period Symptoms cause clinically significant impairment

Trash

Trash is empty.

OneStep Scribe

Provider Login - OneStep Scribe

Email

Password

By signing in you agree to our Terms of Use

HIPAA Compliant Encrypted BAA Available

Having trouble? Contact [email protected]

OneStep Scribe

Set Up Beta Access

Verify your NPI and create your password.

NPI

New Password Confirm Password

At least 12 characters
Uppercase letter
Lowercase letter
Number
Symbol

No patient or clinical information is needed here. Support: [email protected]

Review Note

Esc

Patient Handout

Select a handout type above to generate patient-friendly content

Urgent Alert

Admin Settings

Controlled beta user access

Beta accounts are admin-created only. Do not share accounts. Do not enter PHI into support requests.

Provider Registry

Provider Directory

Find beta providers by name, email, role, invite status, or NPI last four.

0Providers

0Matches

Find Provider

No users loaded

Search

0 active 0 pending

Open Settings to load beta providers.

Add Provider

Create and send invite

The provider receives an email link, verifies their NPI, then creates their own password.

Name Email NPIProvider verifies this NPI before setting a password.

Role Status

My Scales

Click a scale to fill - Scores auto-populate into note

Pinned Scales

Available to Add

Medication Bookshelf - click to pin

Select dose to insert into note

My Templates

No templates yet.
Click + New to create one.

New Template

Template Name *

Body *

Scale Bookshelf - click to swap into slot

DSM-5TR - click to pin

New Appointment -

This time slot conflicts with an existing appointment

Visit Type *

Mode

In Person Phone Call Telehealth

Status

Date *

Duration

Start Time *

Reason (optional)

Today

Medications

Select a medication

100%

<- Choose a medication from the list

Generate patient handout for this dose:

Clicking a dose opens medication education for copy or print. Diagnosis education can be added to the note from Patient Handout.

DSM-5TR

Diagnostic Criteria Reference

Select a diagnosis

100%

<- Choose a diagnosis from the list

Diagnostic Rule

Exclusions

CPT Code Selector

Click a code to pin it to the tile

Evaluation & Management

99202

New Patient - Level 2

Straightforward medical decision making

99203

New Patient - Level 3

Low complexity medical decision making

99204

New Patient - Level 4

Moderate complexity medical decision making

99213

Est. Patient - Level 3

Low complexity medical decision making

99214

Est. Patient - Level 4

Moderate complexity medical decision making

Psychiatric

90792

Psych Eval w/ Medical

Psychiatric diagnostic eval with medical services

90833

Add-on Psychotherapy

30 min psychotherapy add-on to E&M

99214
+90833

99214 + Psychotherapy

Est. Level 4 + 30 min add-on therapy

99204
+90833

99204 + Psychotherapy

New Level 4 + 30 min add-on therapy