AI Medical Scribe for
Clinic days full of new consults, MRI reviews, and post-op checks — each needing ROM degrees, special tests, and a documented surgical rationale. Medical Scribe drafts the note while you examine the shoulder.
A real example of the documentation Medical Scribe generates for shoulder surgeons — ready before your patient leaves the room.
56M — right shoulder pain 6 months after a fall from a ladder. Failed 12 weeks of physical therapy and one subacromial injection. MRI: full-thickness supraspinatus tear. For arthroscopic repair.
Right lateral shoulder pain radiating to the deltoid insertion, VAS 6/10, night pain waking him 3-4 times weekly. Weakness with overhead work — patient is an electrician. Completed 12 weeks of PT with modest relief; subacromial corticosteroid injection in March gave 3 weeks of benefit. Ibuprofen 400 mg PRN. No prior shoulder surgery. NKDA, no metal allergies.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Thirty-plus patients mixing new rotator cuff consults, instability workups, and six-week post-ops — every one owed a complete note before the OR day starts tomorrow.
Forward flexion in degrees, external rotation at the side, strength grading, Jobe, Hawkins, lift-off — findings for each shoulder have to reach the chart exactly as elicited.
Approvals and consents rest on documented failed conservative care, imaging findings, and the risk discussion. A thin consult note stalls the case before it's scheduled.
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.
A shoulder practice cycles patients through consult, conservative care, surgery, and rehab checks. Medical Scribe records each visit — clinic or telehealth — and drafts the note as you go: the mechanism and failed treatments at consult, the risk discussion at booking, healing and ROM progression at follow-ups. You review and sign between patients.
The built-in Shoulder Surgeon’s note template — one of 280+ specialty templates — structures each visit into Subjective, Objective, and a numbered Assessment & Plan covering surgical and non-surgical options, pre-operative preparation, and the post-operative care plan. Spoken exam findings — degrees, strength grades, special tests — land under Objective as dictated.
Every operative decision eventually gets examined — by a payer, a colleague, or counsel. Because your note is drafted from the actual consult, the failed PT, the injection response, the MRI discussion, and the consent conversation are all on record from day one, in your own words, signed by you.
Yes. Call out your exam as you perform it — 'forward flexion 150, Jobe positive' — and each finding is documented under Objective exactly as stated. The Shoulder Surgeon's note never fills in a measurement or test you didn't voice.
The consult note documents what reviewers require: duration of symptoms, completed conservative care and its results, imaging findings, and your operative rationale — organized issue by issue in the Assessment & Plan.
Yes. A 5-minute wound check generates a proportionate note — healing status, ROM progress, therapy stage, next milestone — so post-op clinics don't create an evening of charting.
Medical Scribe is HIPAA compliant with encryption in transit and at rest, and every note is reviewed, edited, and signed by you before it enters the chart. It works for in-person and telehealth consults.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.