AI Medical Scribe for
Thirty-patient clinics wedged between OR days, and every consult needs ROM numbers, imaging findings, and a documented surgical discussion. Medical Scribe drafts the note from the exam-room conversation so the dictation backlog disappears.
A real example of the documentation Medical Scribe generates for orthopedic surgeons — ready before your patient leaves the room.
67F with 3 years of progressive right knee pain, worse on stairs and after prolonged sitting. Pain 7/10 (VAS) walking beyond 20 minutes. Failed 12 weeks of physical therapy, naproxen 500mg BID, and an intra-articular corticosteroid injection in March with only 6 weeks of relief. No locking or giving way. Goals: return to her walking group and keeping up with grandchildren.
Daughter present for the discussion. Expected recovery timeline and home preparation reviewed. Anesthesia questions deferred to pre-operative assessment clinic.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
New consults, post-ops, and injection visits stack 30 or more deep on clinic days — and the dictation queue follows you into the evening before tomorrow's cases.
Range of motion in degrees, strength grades, laxity tests, joint-line findings — you announce them during the exam, then re-enter every value when you finally chart.
Failed conservative care, the risks discussed, the alternatives offered — prior authorization reviewers and med-legal files both look for the same documentation, and thin notes fail both.
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 consults, post-op checks, injection visits, fracture follow-ups — Medical Scribe records each encounter, in the exam room or on a telehealth call, and drafts the note while you move to the next room. Announce your exam findings as you always do; they land in the draft, not in a dictation queue.
The Orthopaedic Surgeon’s note structures the visit into Subjective — mechanism, prior treatments and responses, activity goals; Objective — the musculoskeletal and neurovascular exam with imaging results; and an issue-by-issue Assessment & Plan covering diagnosis, planned investigations, surgical and non-surgical options, pre- and post-operative planning, and referrals.
When a case is questioned — by a payer, or years later in a claim — what counts is the documented discussion: failed conservative care, risks explained, alternatives offered. Medical Scribe captures that conversation as it actually happened, and never inserts anything that wasn’t said.
Yes. Values you call out during the exam — degrees of motion, strength grades, stability findings — are documented in the Objective section of the Orthopaedic Surgeon's note as stated. It never invents a measurement, and you verify before signing.
The note records what was actually covered in the visit: the duration of symptoms, each failed conservative treatment and its outcome, imaging findings, and the surgical discussion — the elements reviewers check for. You review and sign before it goes to the chart.
Yes. Follow-ups produce concise notes with wound status, rehab progress, and plan updates, and you can build custom templates in minutes for recurring visit types — alongside 280+ built-in templates including the Orthopaedic Surgeon's note.
Medical Scribe is HIPAA compliant, with encryption in transit and at rest. It records in-person and telehealth visits on iOS, Android, Web, Apple Watch, and Mac.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.