AI Medical Scribe for
Thirty-patient clinic days of carpal tunnels, trigger fingers, and distal radius follow-ups leave no time to type Tinel's signs and ROM degrees. Medical Scribe drafts your consult note — exam measurements, consent discussion, and surgical plan included.
A real example of the documentation Medical Scribe generates for hand surgeons — ready before your patient leaves the room.
54F, right-hand-dominant administrative assistant, referred with 4 months of numbness and tingling in the right thumb, index, and middle fingers. Wakes at night shaking the hand for relief; increasingly drops small objects. Neutral wrist splint x3 months with partial relief. No neck pain, trauma, or bilateral symptoms. PMH: hypothyroidism on levothyroxine 75mcg daily. No anticoagulants. NKDA. Non-smoker.
Right carpal tunnel syndrome, moderate on electrodiagnostics, refractory to 3 months of splinting. Discussed open carpal tunnel release under local anesthesia: risks reviewed including infection, scar and pillar pain, nerve injury, and incomplete symptom relief; nonoperative alternatives revisited. Patient elects to proceed with surgery.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
A full clinic day of new consults, post-op checks, and injections means dozens of notes — each needing a focused history, exam, and plan before the next patient is roomed.
Two-point discrimination, Tinel's and Phalen's, grip strength, ROM in degrees — granular findings that are tedious to type and dangerous to shortcut.
Risks, benefits, and alternatives discussed before a carpal tunnel release or ORIF are only defensible if the chart shows the conversation actually happened.
Real-time transcription that understands medical terminology and clinical context.
Recognizes terms, conditions, and procedures specific to your practice area.
Generate comprehensive clinical notes in minutes instead of hours.
Enterprise-grade encryption and security to protect sensitive data.
These aren't generic formats — they ship in the product today, structured around how you actually document.
Plus 280+ templates across every specialty — or build your own in minutes.
New referrals, post-op wound checks, splint reviews, corticosteroid injections — Medical Scribe records each encounter, in clinic or via telehealth, and drafts a note matched to it. A two-minute suture removal gets two lines; a surgical consult gets the full history, exam, and operative discussion. You review and sign before it goes in the chart.
Drafts follow the built-in Hand Surgeon’s Note template: Subjective with presenting complaint, surgical history, and anticoagulant use; Objective with exam findings and investigation results like NCS/EMG; and Assessment & Plan structured per surgical issue — differential, planned procedure, pre-operative preparation, and post-operative care. It is one of 280+ specialty templates, and custom versions take minutes.
When a patient later asks what was agreed — or a payer asks why surgery was indicated — the note shows the failed splinting, the electrodiagnostic findings, and the consent discussion in your own words from the visit. Medical Scribe never adds findings or reasoning you didn’t state.
Yes. Numbers you say aloud during the exam — degrees of motion, kilograms of grip, millimeters of discrimination, Tinel's and Phalen's results — land in the Objective section of the note exactly as stated. Nothing is measured for you, and nothing is invented.
Yes. The Hand Surgeon's Note template includes patient education and informed consent within its Assessment & Plan structure, so the risks, benefits, and alternatives you discussed — and the patient's decision — are captured in the visit note itself.
Each visit generates its own draft as soon as the recording ends, whether it was a 10-minute post-op check or a 40-minute new consult. You review and sign between patients or in one batch — no dictation backlog at day's end.
Medical Scribe is HIPAA compliant, with encryption in transit and at rest. Recordings and notes are processed securely, and nothing enters the chart until you have reviewed and signed it.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.