An AI operative note for orthopedic surgery turns a two-minute dictation between cases into a complete, signed-ready op report. Mira Scribe structures your dictation into your own template, with laterality, approach, findings, implants, closure, and estimated blood loss each in the right section, and maps the report to CPT, ICD-10, and modifiers before you sign. It captures laterality on 100% of operative notes and reports 97% first-pass accuracy on orthopedic documentation. It integrates natively with Epic, athenahealth, ModMed, eClinicalWorks, NextGen, and DrChrono, and builds new EHR integrations in one to four weeks.
This page covers operative notes. For clinic visit documentation and the full product, see Mira Scribe.
Why Op Note Dictation Still Eats Your Day
Most surgeons finish the case, then face a choice. Dictate now and hold up turnover, or batch the op notes at the end of the day when the details of case three have blurred into case six. Either way the op note sits unsigned, and the claim for the surgery waits with it.
Traditional op note dictation has three recurring problems:
- Transcription turnaround. The note comes back hours or days later and still needs edits.
- Missing elements. EBL, implant lot details, or the tourniquet time get skipped, and someone has to chase them.
- Coding gaps. The op note says what happened, but the biller still has to translate it into codes and modifiers, and a missing side or an unclear compartment turns into a denial.
What a Coding-Ready Orthopedic Operative Report Contains
Mira builds each op note from your template. A standard orthopedic operative report includes:
| Section | What Mira captures from your dictation |
|---|---|
| Diagnosis | Pre- and postoperative diagnosis mapped to a specific ICD-10 code |
| Procedure | Procedure name with laterality on the procedure line |
| Anesthesia | Type, including regional blocks |
| Approach | Incision, interval, and exposure |
| Findings | What you saw: chondral grade, tear pattern, fracture pattern |
| Implants | System, component sizes, fixation, screw counts and lengths |
| Closure | Layered closure, drains, dressing |
| EBL and tourniquet | Estimated blood loss and tourniquet time |
| Disposition | Condition and destination after the case |
You dictate in whatever order you think. Mira puts each detail where it belongs.
Op Note Templates by Procedure
Total knee arthroplasty
For a total knee (CPT 27447), Mira places the approach, the femoral and tibial component sizes, poly thickness, patellar resurfacing, cement, and tourniquet time in their sections. The side carries to the -LT or -RT modifier.
ACL reconstruction
An arthroscopic ACL reconstruction (CPT 29888) note needs graft type and harvest site, tunnel placement, fixation, and any concomitant meniscal work. When you also address the meniscus, Mira records the compartment so the coder can see exactly what was done where.
Rotator cuff repair
For an arthroscopic rotator cuff repair (CPT 29827), Mira captures tear size and pattern, tissue quality, anchor count, and any subacromial decompression or biceps procedure performed in the same session.
ORIF
An ORIF of a distal radius fracture (CPT 25607) note needs the fracture pattern, reduction technique, plate and screw construct, and fluoroscopy confirmation. Mira structures each one and maps the fracture diagnosis to a specific ICD-10 code.
Spine fusion
A lumbar interbody fusion (CPT 22633) report has levels, approach, decompression, interbody device, pedicle screw sizes by level, bone graft, and neuromonitoring. Mira keeps levels and hardware organized so the report reads cleanly and the levels are clear for coding.
From Dictation to Signed Op Note
- Dictate. Use the Mira mobile app or a workstation right after the case. Speak naturally; you do not need to follow the template order.
- Review. Mira drafts the full report in your template, so a blank EBL or implant field is easy to spot before you sign.
- Sign. You edit if needed and sign. The note goes to your EHR.
- Code. CPT, ICD-10, and modifiers are suggested from the signed note, each tied to the documentation that supports it.
Surgeons who dictate between cases can sign the op note before they leave the hospital, which means the surgical claim can move the same day.
Laterality, Modifiers, and Coding From the Op Note
The op note is the source document for the surgical claim, so small gaps matter. Mira carries the side from your dictation into -LT, -RT, or -50. When an assistant surgeon or co-surgeon is documented, the report reflects it so modifiers like -80, -AS, or -62 can be supported. When a case was unusually difficult, a clear description in the op note is what supports -22.
When Mira Scribe is paired with Mira RCM, the op note, the codes, and the claim come from the same source.
Op Note AI vs. Transcription Service vs. Typing
| Typing in the EHR | Transcription service | Mira Scribe | |
|---|---|---|---|
| Surgeon time | Longest; done after clinic | Short dictation, then edits | Short dictation, then a quick review |
| Turnaround | Whenever the surgeon gets to it | Hours to days | Draft ready right after you dictate |
| Structure | Depends on the surgeon | Free text in a template | Each detail in its template section |
| Coding | Coder reads and codes | Coder reads and codes | CPT, ICD-10, and modifiers suggested from the note |
Results
| Metric | Mira Scribe |
|---|---|
| Laterality capture on op notes | 100% |
| First-pass accuracy on orthopedic documentation | 97% |
| Time saved per note | ~12 minutes |
| Time to go live | 48 hours |
How to Evaluate Op Note AI
Bring two real cases to a demo: a straightforward total knee and the most complicated case you did last month. Dictate them the way you normally would. Then check what lands in the report: is the side right on the procedure line, are the implant sizes in the implant section, is EBL there, and would your coder have everything needed without calling you?
For a broader comparison of tools, read Best AI Scribes for Orthopedic Surgeons (2026).
Get Started
Mira Scribe goes live in 48 hours, with your op note templates configured before your first case. See Mira Scribe or book a demo and bring one real op note.