SPECIALTY · ORTHOPEDICS

AI medical scribe for orthopedics

An orthopedic note lives or dies on specifics: which side, how it happened, how far it moves now. ScribeLive captures laterality, mechanism of injury, range of motion and the imaging you reviewed, and carries them forward through the post-operative follow-ups.

Sample orthopedics SOAP note

An 11-minute six-week review after right ACL reconstruction. ScribeLive drafted it; the surgeon changed nothing.

ASSESSMENT & PLAN · BY PROBLEM

1. Aftercare following right ACL reconstruction (Z47.89)

Hamstring autograft, six weeks post-operative. Wounds healed, no erythema or effusion. Patient reports discomfort only with exercise, none at rest.

2. Range of motion, right knee

Active flexion 0–115°, up from 0–95° at the three-week review. Full passive extension. Quadriceps activation present, strength 4/5 against resistance.

3. Plan

Continue phase two of the rehabilitation protocol. Stationary cycling permitted; no pivoting or cutting. Review in six weeks with repeat range-of-motion measurement.

ICD-10 Z47.89Protocol: ACL rehab phase 2 · ROM target met

Why orthopedic surgeons use ScribeLive instead of a general-purpose scribe

Laterality is never guessed

Left and right are taken from what was said in the room and written explicitly, because an orthopedic note that gets the side wrong is worse than no note at all.

Measurements carry forward

Each follow-up shows the previous range of motion next to today's, so progress is visible without opening the last chart.

Rehab protocols are checked in the room

Your own post-operative protocol appears as a live checklist during the visit, and whether it was followed is recorded in the note.

Orthopedics FAQ

Does it get left and right correct?

Laterality is drafted from what was said in the visit and shown explicitly in the note. As with everything in the draft, check it before signing — this is the one field worth reading twice.

Can it carry findings between visits?

Yes. Follow-up notes show the previous visit's measurements alongside today's, which is how progress gets documented without retyping it.

Does it suggest billing (CPT / E&M) codes?

Not today. ScribeLive suggests ICD-10 diagnosis codes; billing codes stay with your existing process.