AI Medical Scribe for Orthopedics

Common documentation challenges in orthopedics

Orthopedic documentation is detail-heavy by nature. A single knee evaluation involves inspection, palpation, range of motion in multiple planes, several special tests (Lachman, McMurray, varus/valgus stress), neurovascular assessment, and gait observation. Capturing all of this accurately while maintaining eye contact with the patient is difficult without a scribe or after-hours charting.

Imaging adds another layer. Most orthopedic visits involve reviewing X-rays, MRIs, or CT scans with the patient. The discussion of findings, clinical significance, and treatment implications needs to be documented in the note — but often gets reduced to a single line because writing it out takes too long.

Coordination documentation is equally challenging. Referral letters to physical therapy need to include the diagnosis, relevant imaging, weight bearing status, and specific goals. Post-surgical follow-up notes must track progress against expected recovery timelines. Physical therapy coordination requires clear documentation of restrictions and progression criteria.

Visit types Dictum supports

Dictum generates documentation drafts across orthopedic encounter types. The AI adapts its output to the clinical content discussed rather than forcing every visit into an identical template.

For visits that combine multiple concerns — a patient returning for a shoulder post-op who also wants to discuss new wrist pain — Dictum separates documentation by problem so each issue gets its own assessment and plan.

How Dictum helps orthopedic clinicians

Dictum works with the ambient AI scribe mode during patient encounters. It listens to the conversation — your exam narration, imaging discussion, and treatment planning — and generates a structured note draft afterward. You interact with the patient the same way you always have.

The AI captures detailed physical exam findings organized by joint and region. When you describe range of motion, perform special tests, or note tenderness on palpation, Dictum maps these to the appropriate Objective subsections. Laterality, severity descriptors, and comparison to the contralateral side are preserved in the output.

Imaging discussions are documented with the modality, key findings you describe to the patient, and your interpretation. When you explain an MRI showing a partial rotator cuff tear or an X-ray with medial joint space narrowing, that clinical reasoning appears in the note.

Dictum also drafts referral letters to physical therapy, pain management, or surgical colleagues. These include the relevant history, exam findings, imaging results, and your specific referral question or therapy goals.

Documentation outputs

Dictum generates several documentation types relevant to orthopedic practice:

• Orthopedic SOAP notes — structured with joint-specific exam sections, imaging findings, and laterality throughout. See AI SOAP note generation for details on section mapping.
• Referral letters — to physical therapy, surgery, or pain management, including diagnosis, imaging summary, and specific goals or questions. See referral letters.
• After-visit summaries — patient-facing summaries with activity restrictions, weight bearing status, follow-up timing, and when to seek urgent care. See after-visit summaries.
• Custom templates — documentation formats tailored to your specific orthopedic visit types or subspecialty focus. See custom clinical templates.

All outputs are plain text compatible with any EHR note field — Epic, Cerner, Athena, or your practice management system.

Example orthopedic note structure

Here is how Dictum structures a typical orthopedic encounter note:

The specific content varies by visit type. A post-surgical follow-up emphasizes wound inspection, milestone tracking, and therapy progression. A new injury evaluation focuses on mechanism, exam findings, and diagnostic workup. Dictum adapts the structure to match what was discussed.

Security and clinician review

Every note Dictum generates is a draft. It does not enter any EHR automatically and does not leave the application unless you explicitly copy or export it. The review step is where your clinical expertise matters most — verifying exam findings are accurately captured, ensuring laterality is correct, and confirming the plan reflects your clinical decision-making.

Audio recordings are processed in real time and not retained on our servers after transcription. Generated notes are encrypted and stored in your Dictum account until you choose to export or delete them. Dictum is designed to meet HIPAA requirements for handling protected health information.

For details on available plans and usage, see Dictum pricing. For a broader look at how Dictum works across clinical specialties, visit the specialties overview.