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AI optometry scribeLive

The AI medical scribe for optometry. The whole exam, into your EHR's fields.

Ambient voice documentation for the eye exam. Doctora listens in the lane, transcribes the exam and drafts the structured chart by structure and per eye, with the ICD-10 and CPT codes. The doctor confirms it. Then it writes the fields into the EHR.

First 10 charts free · Cancel anytime before your 10th chart · HIPAA compliant

Jordan Sample, 61 · Comprehensive examSample exam
Entrance Vision
UnaidedAided
DistNearDistNear
OD20/5020/5020/2520/30
OS20/6020/5020/2520/30
OU20/4020/4020/2020/25
Refraction
SphCylAxisAdd
OD−2.25−0.75175+1.75
OS−2.00−1.00005+1.75
BVA
OD20/20OS20/20OU20/20
PD
63
NRA/PRA
NRA +2.00 / PRA -2.50
Anterior Segment
TonometryOD16OS17mmHg· Goldmann@ 10:41
Adnexa / OrbitNormalOU
Lids & LashesMeibomian Gland DysfunctionOU
Tear FilmNormalOU
Palpebral ConjunctivaPink & SmoothOU
Bulbar ConjunctivaWhite & QuietOU
Sclera / EpiscleraWhite & QuietOU
CorneaODSPK Grade 1OSClear
Anterior ChamberDeep & QuietOU
AnglesVan Herick Grade IV (Open)OU
IrisFlat and ClearOU
LensNuclear Sclerosis Grade 1OU
Posterior Segment
DilationDilatedOU· Tropicamide 1%@ 10:52
VitreousClearOU
Optic DiscClear, Pink, Distinct 360OU
C/D Ratio0.35 / 0.40 H/VOU
VesselsA/V Ratio: Greater than 2/3, A/V Crossings: NormalOU
MaculaFlat & ClearOU
Posterior PoleClearOU
PeripheryClear & Flat, No Holes/BreaksOU
Diagnoses4 diagnoses
1°H40.1131Primary open-angle glaucoma, bilateral, mild stagePrimary open-angle glaucoma, bilateral, mild stage
Laterality
ODOSBoth
Severity
Mild
Care plans
Repeat OCT ONH + RNFL, both eyes
RTC 6 months, IOP check
Justifies92014Comprehensive eye exam, established patient92083Visual field examination, extended
H25.13Age-related nuclear cataract, bilateralAge-related nuclear cataract, bilateral
Laterality
ODOSBoth
Care plans
Monitor; review glare and night driving at the next visit
Justifies92014Comprehensive eye exam, established patient
H52.223Regular astigmatism, bilateralRegular astigmatism, bilateral
Care plans
Updated spectacle Rx finalized today
Soft toric contact lenses fit; follow-up in 2 weeks
Justifies92015Refraction92310Contact lens fitting, both eyes
H52.4PresbyopiaPresbyopia
Care plans
Add +1.75 for near; progressive lenses discussed
Justifies92015Refraction
Billing
Exam driver92014Comprehensive eye exam, established patient
RoutineMedical
NewEstablished
Doctor's choice
Additional codes
92083Visual field examination, extended
JustifiedH40.1131Primary open-angle glaucoma, bilateral, mild stage
92015Refraction
JustifiedH52.223Regular astigmatism, bilateralH52.4Presbyopia
92310Contact lens fitting, both eyes
JustifiedH52.223Regular astigmatism, bilateral
Sent to RevolutionEHR, 11 of 11 sections11:06
Writing fields into RevolutionEHR
Sent to RevolutionEHR, 11 of 11 sections11:06
A note is not a chart

Other scribes hand you a paragraph. Doctora fills the fields.

A dictated note still ends in your exam form one box at a time: refraction here, pressures there, each slit lamp structure on its own line. Doctora writes the boxes, per eye, with the codes attached. Nothing to re-type, nothing to paste.

A dictated noteWhat a general scribe returns

Established patient in for a comprehensive exam, reports blur at distance and near and glare driving at night. Entrance vision twenty-fifty right, twenty-sixty left, twenty-twenty-five with correction. Refraction right eye minus two twenty-five, minus seventy-five, axis one seventy-five; left eye minus two, minus one, axis five; add plus one seventy-five, twenty-twenty each eye. Pressures sixteen and seventeen by Goldmann. Lids show meibomian gland dysfunction both eyes, grade one punctate staining right, grade one nuclear sclerosis both eyes, angles open. Dilated: cup-to-disc point three five by point four both eyes, discs pink and distinct, macula clear. Open-angle glaucoma, mild, both eyes, repeat OCT and fields, back in six months for pressures. Nuclear cataract, monitor. New spectacle Rx and a soft toric contact lens fit, two weeks for the lens check.

Still typed into the exam form by hand, one box at a time
The fields Doctora writesSame visit, into your exam form
  • Chief complaintBlur at distance and near, glare at night
  • Final RxOD −2.25 −0.75 ×175 · Add +1.75
  • Final RxOS −2.00 −1.00 ×005 · Add +1.75
  • TonometryOU 16 · 17 mmHg · Goldmann 10:41
  • Lids & lashesOU Meibomian gland dysfunction
  • CorneaOD SPK grade 1
  • LensOU Nuclear sclerosis grade 1
  • C/D ratioOU 0.35 / 0.40
  • CL fitSoft toric, 92310
  • DiagnosisH40.1131 Primary open-angle glaucoma, bilateral, mild
  • Exam code92014, linked to H40.1131 · 92083 visual field
Confirmed by the doctor, sent to the EHR
How it works in the lane

Same exam, same tech, same EHR. Different ending.

Doctora fits the lane you already run. What changes is what you do after the patient leaves: read and confirm, instead of type.

01

The tech pretests as usual

Auto-refraction, pressures, entrance acuities, history: the tech enters them the way they do today. Doctora keeps what the tech entered and shows who entered what.

Nothing changes for the tech
02

The doctor talks through the exam

In the lane, in your own words: trace SPK inferior OU, C/D point three five, one plus NS right. No commands, no headings. Say it to the patient and it is said to the chart.

Your words
03

Doctora drafts the chart and the codes

Refraction, pressures, each slit lamp and fundus structure, CL fit, OD and OS apart, then the ICD-10 diagnoses and the CPT codes they support, with new or established from the patient’s own record.

Per eye, per structure
04

The doctor confirms

Read it like a tech work-up. Change a value in place, drop a finding, pick the exam code, choose routine or medical. Nothing leaves the screen until you say so.

You decide
05

Sent to your EHR, section by section

The confirmed fields land in your own exam form and the codes with them. The row at the bottom tells you which sections arrived, so finishing the chart means reading it, not re-typing it.

Into the actual fields
AI medical scribe

What is an AI medical scribe for optometry?

An AI medical scribe listens to the exam and writes the record, so the doctor reads and confirms instead of typing. For optometry, the record is a structured chart, not a note.

The termsWhat each one means at Doctora

AI medical scribe

Software that turns the spoken exam into the medical record. A general AI scribe writes a paragraph note. Doctora is an AI scribe built for optometry, so it writes the eye exam chart: history, pretesting, refraction, slit lamp, fundus, CL fit, assessment and plan.

Ambient AI scribe

Doctora listens in the background while you talk to the patient. No commands, no headings, no dictating to the screen. You keep your eyes on the patient and the chart is drafted from the exam itself.

Voice documentation

Charting by voice instead of the keyboard. Say the finding the way you already do, trace SPK inferior OU, and it lands on that structure’s row for that eye.

Medical transcription

Doctora transcribes the exam and drafts the chart from the transcript. It detects the language of the visit, including Cantonese and Mandarin with switching mid visit.

Structured exam chart

The fields your EHR already has, filled by structure and per eye, with the ICD-10 and CPT codes linked. The doctor confirms the chart before anything is written into the EHR.

By structure, per eye

Slit lamp and fundus, one row per structure, OD and OS apart.

Lids and lashes, tear film, cornea, chamber, angles, iris, lens, then vitreous, disc, C/D, macula, vessels, pole and periphery. Say the finding and it lands on the structure's row for that eye. A normal structure stays normal.

Sample exam
Anterior Segment
TonometryOD16OS17mmHg· Goldmann@ 10:41
Adnexa / OrbitNormalOU
Lids & LashesMeibomian Gland DysfunctionOU
Tear FilmNormalOU
Palpebral ConjunctivaPink & SmoothOU
Bulbar ConjunctivaWhite & QuietOU
Sclera / EpiscleraWhite & QuietOU
CorneaODSPK Grade 1OSClear
Anterior ChamberDeep & QuietOU
AnglesVan Herick Grade IV (Open)OU
IrisFlat and ClearOU
LensNuclear Sclerosis Grade 1OU
Sample exam
Posterior Segment
DilationDilatedOU· Tropicamide 1%@ 10:52
VitreousClearOU
Optic DiscClear, Pink, Distinct 360OU
C/D Ratio0.35 / 0.40 H/VOU
VesselsA/V Ratio: Greater than 2/3, A/V Crossings: NormalOU
MaculaFlat & ClearOU
Posterior PoleClearOU
PeripheryClear & Flat, No Holes/BreaksOU
What gets charted

Every section of the exam, in the shape your EHR expects.

Structured means each finding is a value in a named field, per eye where the exam is per eye. Specialty tests for dry eye, binocular vision, glaucoma and myopia are on Doctora Pro.

Background

History lands in the sections your EHR already has. Medications and allergies arrive as separate entries, not one paragraph at the top of the chart.

  • Chief complaint
  • History of present illness
  • Ocular history
  • Medical history
  • Medications
  • Allergies
  • Family and social history
Examination

Findings are values, per eye. Refraction arrives as sphere, cylinder, axis and add for OD and OS, pressures as a number with the method and time, each slit lamp and fundus structure on its own line.

  • Entrance acuityODOS
  • Pupils, EOM, confrontation fields
  • Refraction and final RxODOS
  • TonometryODOS
  • Slit lampODOS
  • DilationODOS
  • FundusODOS
  • Contact lens fitODOS
Assessment and plan

Diagnoses carry their ICD-10 codes, procedures their CPT codes, and each plan is attached to the diagnosis it treats. The doctor confirms all of it before it is sent.

  • Diagnoses
  • Exam and procedure codes
  • Care plans
  • Follow-up
  • Spectacle RxODOS
  • Contact lens RxODOS
Coding

Codes the doctor confirms

The chart and the codes come from the same exam, so they agree. You read them together and send them together.

  • Diagnoses and procedures, linked

    ICD-10 and CPT are suggested from the exam, and each code is linked to the diagnosis that supports it.

  • New or established, from the record

    Doctora reads the patient's own record to see whether the visit is new or established.

  • Cataract post-op visits

    Coded 66984-55 with no exam code, automatically, unless the practice turns it off.

  • Learns your habits

    Doctora learns each doctor's vocabulary and code habits, so the next suggestion looks like yours.

  • The doctor decides

    The doctor confirms every code and chooses routine or medical. Doctora never decides that.

Sample exam
Diagnoses4 diagnoses
1°H40.1131Primary open-angle glaucoma, bilateral, mild stagePrimary open-angle glaucoma, bilateral, mild stage
Laterality
ODOSBoth
Severity
Mild
Care plans
Repeat OCT ONH + RNFL, both eyes
RTC 6 months, IOP check
Justifies92014Comprehensive eye exam, established patient92083Visual field examination, extended
H25.13Age-related nuclear cataract, bilateralAge-related nuclear cataract, bilateral
Laterality
ODOSBoth
Care plans
Monitor; review glare and night driving at the next visit
Justifies92014Comprehensive eye exam, established patient
H52.223Regular astigmatism, bilateralRegular astigmatism, bilateral
Care plans
Updated spectacle Rx finalized today
Soft toric contact lenses fit; follow-up in 2 weeks
Justifies92015Refraction92310Contact lens fitting, both eyes
H52.4PresbyopiaPresbyopia
Care plans
Add +1.75 for near; progressive lenses discussed
Justifies92015Refraction
Billing
Exam driver92014Comprehensive eye exam, established patient
RoutineMedical
NewEstablished
Doctor's choice
Additional codes
92083Visual field examination, extended
JustifiedH40.1131Primary open-angle glaucoma, bilateral, mild stage
92015Refraction
JustifiedH52.223Regular astigmatism, bilateralH52.4Presbyopia
92310Contact lens fitting, both eyes
JustifiedH52.223Regular astigmatism, bilateral
Concept Library LiveOn Doctora Pro

Add the specialty tests your practice runs.

Specialty tests for dry eye, binocular vision, glaucoma and myopia that you add to your chart template. Doctora listens for them and writes each one into its own field, per eye.

Dry eye
Tear Break-Up Time (TBUT)Specialty test
Tear Break-Up Time (TBUT)
OD6s
OS7s
Assessment
Method
Notes
Notes
Schirmer TestSpecialty test
Wetting (mm)
OD12mm
OS14mm
Saturated
OD
OS
Variant
Duration (min)
5min
Notes
Notes
MeibographySpecialty test
Upper Lid Loss (%)
OD25%
OS20%
Lower Lid Loss (%)
OD30%
OS25%
Notes
Notes
Binocular vision
Near Point of Convergence (NPC)Specialty test
Break (cm)
6cm
Recovery (cm)
9cm
Notes
Notes
StereopsisSpecialty test
Stereoacuity (arcsec)
40arcsec
Method
Notes
Notes
Glaucoma
Pachymetry (CCT)Specialty test
Pachymetry (CCT)
OD548µm
OS552µm
Myopia
Axial LengthSpecialty test
Axial Length
OD24.31mm
OS24.18mm

Tests you can add

Dry eye
  • Tear Break-Up Time (TBUT)
  • Schirmer Test
  • Meibomian Gland Evaluation
  • Ocular Surface Staining
  • Tear Meniscus Height
  • Lipid Layer Interferometry
  • Meibography
  • Demodex Collarettes
Binocular vision
  • Near Point of Convergence (NPC)
  • Stereopsis
  • Amplitude of Accommodation
  • Accommodative Response (FCC / MEM)
  • AC/A Ratio
  • Worth 4-Dot
Glaucoma
  • Pachymetry (CCT)
  • Gonioscopy
  • OCT RNFL Thickness
  • OCT Ganglion Cell Analysis
  • Visual Field Indices
Myopia
  • Axial Length
  • Retinoscopy

Your practice picks the tests. Everything else in the chart stays as it is. See what Pro includes.

Compared

AI scribe vs traditional documentation

Every way of charting ends in the same exam form. What differs is who fills it in, and how much is left for the doctor afterwards.

Ways to chart an eye exam

Typing it yourself

You chart between patients or after clinic, one box at a time: refraction here, pressures there, each slit lamp structure on its own line.

A human medical scribe

Someone in the lane types while you work. You hire, train and schedule them, and the chart still depends on what they caught.

Dictation and voice transcription

Voice to text. You get a paragraph, and the words still have to be moved into the right fields of your exam form.

Doctora’s AI scribe

An ambient AI scribe for optometry. It listens to the exam, transcribes it, drafts every field with the codes, and writes the chart the doctor confirmed into the EHR’s fields.

Pricing

Per doctor. Techs, front desk and billing are free accounts.

Try Doctora free for your first 10 charts.

Doctora Core

Complete AI charting for an optometrist's everyday clinical workflow

  • Complete eye exams and contact lens fittings
  • AI chart generation and EHR write-back
  • Automated coding and care plans
  • Standard-field instructions and exam templates
  • Unlimited staff accounts and multi-location
$249per doctor per month
or $199 per doctor per month, billed annually

Doctora Pro

Specialty depth and whole-practice workflows beyond the standard exam

  • Everything in Doctora Core
  • Tech-to-doctor staged generation (Beta)
  • Longitudinal patient-history context
  • New fields and specialty workflows (Beta)
  • Payer-aware claim guidance (Beta)
  • Intake and eligibility (Beta)
$499per doctor per month
or $399 per doctor per month, billed annually
Questions

Questions doctors ask about the AI scribe.

Is Doctora an ambient AI scribe or a dictation tool?

An ambient AI scribe. Doctora listens to the exam in the background, transcribes it and drafts the structured chart from what was said and found. You do not dictate a note or speak in commands; you talk to the patient the way you already do.

Does the doctor see the chart before it reaches the EHR?

Yes. Every field and every code is on the screen for the doctor to read, change in place or remove before anything is sent. Nothing is written into the EHR until the doctor confirms the chart.

What happens to what the tech already entered?

Techs keep pretesting the way they do now. Doctora adds the exam to the chart; it does not overwrite the acuities, pressures or auto-refraction the tech entered. The doctor sees who entered what.

Do I have to say everything out loud?

Talk to your patient the way you already do, in the words you already use: trace SPK inferior OU, C/D point three five, pressures sixteen and seventeen. No commands, no headings. What you do not say stays empty for you to fill in, and what the tech pretested is already there.

Does Doctora help with coding?

Doctora suggests the ICD-10 diagnoses and the CPT codes from what was said and found in the exam, links each code to the diagnosis that supports it, and shows whether the visit is new or established from the patient’s own record. The doctor confirms the codes and chooses the billing route. Doctora never decides routine versus medical.

Can I customize the chart for my practice?

Doctora drafts into the fields your EHR exam template already has, and it learns each doctor’s vocabulary and code habits. On Doctora Pro, the practice adds the specialty tests it runs, such as tear break-up time or pachymetry, and Doctora listens for them and writes each one into its own field, per eye.

What do I need in the exam room?

A microphone in the lane and the computer you already chart on. Doctora also records from an iPhone. There is no new hardware.

Does it work for a practice with several doctors?

Yes. Each doctor who charts has a seat; techs, front desk and billing have free accounts. Doctora Pro adds tech-to-doctor staged charting, where the tech records pretesting and the doctor picks the chart up for the exam.

Which EHRs does Doctora write into?

Doctora writes the exam into six optometry EHRs: RevolutionEHR, CrystalPM, Eyefinity, OfficeMate, Eye Cloud Pro and Uprise. RevolutionEHR, CrystalPM and OfficeMate are live for every practice; Eyefinity, Eye Cloud Pro and Uprise are in beta with the practices who joined while they mature. Each EHR page says what Doctora writes into that chart today. Run a different EHR? Tell us which one.

What if we change EHRs?

Doctora goes with you. The same account, the same doctors and the same charts work with any of the EHRs Doctora writes into today: RevolutionEHR, CrystalPM, Eyefinity, OfficeMate, Eye Cloud Pro and Uprise.

Is Doctora HIPAA compliant?

Yes. Doctora signs a business associate agreement with every practice, audio and charts are encrypted in transit and at rest, and the practice chooses how long audio is kept, down to deleting it once the chart is confirmed.

Can I try it before I pay?

Yes. Your first 10 charts delivered to your EHR are free, and there is no day-based expiry. Your first month of the plan you chose is charged only when your 10th chart is delivered. Cancel anytime before then and you pay nothing. Ask within 7 days of your first charge for a full refund.

Chart your next exam with the scribe.

Record one exam in your own lane. Read the chart, confirm the codes, and watch the fields land in your EHR.

First 10 charts free · Cancel anytime before your 10th chart