AI scribe and clinic software for sports medicine clinics

The sports medicine note follows the injury

A sports medicine note has a fixed order, sport, level and position, mechanism, onset, examination by joint with special tests, imaging decided and why, working diagnosis and plan. wai drafts it in that order from the consultation, with side and structure in fixed fields. The imaging decision belongs in the note too. In a BMJ systematic review of 27 studies covering 15,581 patients, the Ottawa ankle rules had a sensitivity of almost 100% for excluding ankle and mid-foot fractures, and their use was expected to cut unnecessary radiographs by 30 to 40%.⁴ When the clinician applies a rule aloud, the draft records which criteria were met.

Return to play runs alongside rehabilitation. The 2016 Bern consensus statement on return to sport describes it as a continuum running alongside recovery and rehabilitation, and points to the Strategic Assessment of Risk and Risk Tolerance framework for the decision.³ A return-to-play note records the stage reached, the criteria met, the risks discussed and who agreed the next step, so the physio and the athlete read the same plan.

Concussion has its own tools. The 6th international consensus on concussion in sport, held in Amsterdam in 2022, revised the SCAT6 and produced a new office assessment tool, the SCOAT6, for clinic follow-up.¹ In UK grassroots sport, the national guidelines say anyone with a suspected concussion must be removed from play, should not return to competition, training or PE within 24 hours, should follow a graduated return to activity and sport, and should not return to competition before 21 days from injury.² wai drafts the concussion review with the symptom scores and the stage reached as the clinician states them.

wai suggests ICD-10 and SNOMED CT codes from the note, each beside the line it rests on, for the clinician to confirm. Typical WHO ICD-10 codes are S06.0 for concussion, S83.5 for sprain and strain involving the cruciate ligament of the knee, S93.4 for sprain and strain of ankle, S76.3 for injury of the posterior muscle group at thigh level, which covers hamstring injuries, and M76.5 for patellar tendinitis. ICD-10-CM in the US adds characters for side and encounter, so a concussion without loss of consciousness at the first visit is S06.0X0A and a sprain of an unspecified ligament of the right ankle is S93.401A. Procedure codes, CPT in the US and OPCS in the UK, stay with the clinic's coder.

Letters to the athlete, the physio, the club and the school

The Academy of Medical Royal Colleges recommends that most outpatient letters are written to the patient with a copy to the GP, and that writing to patients is the default setting for an AI scribe.⁵ In sports medicine the athlete's letter is the plan they train to, so it sets out the diagnosis, what is allowed now, what comes next and the signs that mean stop and come back.

The physio's letter carries the diagnosis, the imaging, the restrictions, the rehabilitation stage and the criteria for moving on. An imaging request to a radiology clinic carries the clinical question and the decision rule result, and the radiology page covers what happens at the other end. For the rehabilitation side, see physiotherapy and orthopaedics when surgery is on the table.

Clubs, schools and employers want a date. A letter to any of them carries only what the athlete, or a parent for a younger athlete, has agreed to share, usually availability, restrictions and the next review, and the consent is recorded in the note. wai also drafts extenuating circumstances letters when a concussion falls in exam season, fit-to-fly letters for travel to competition and, in the UK, fit notes on the official form.

Athletes in their own language

wai works in 60 languages, among them English, Arabic, Spanish, French, Portuguese, Italian, Russian, Polish, Turkish, Urdu and Mandarin. English can be mixed in one consultation with Spanish, French, Portuguese, Russian, Italian, Dutch, German, Hindi or Japanese, and the other languages are captured in that language. The signed note is written in English for the record, or in another language the clinic chooses, and the athlete's summary can be translated into their language beside it, with crisis and emergency numbers kept exactly as written.

Squads and academies are international. A Brazilian midfielder can describe the injury in Portuguese with English mixed in, and the stage plan he trains to arrives in Portuguese beside the English note his physio reads. In a systematic review of 33 studies, 76% found at least one outcome better when patient and physician shared a language other than English.⁷ See multilingual consultations for how capture works.

Clinic software for sports medicine clinics, stage by stage

A sports medicine plan is a chain of reviews, and each one has to happen on time. wai Admin brings calls, email, web forms and WhatsApp into one thread per athlete and drafts each reply in the clinic's voice for a person to approve, so a coach's message asking about a player is answered only within what the athlete has agreed. Booking links read each clinician's calendar in Google, Outlook or Apple, cancellations backfill from the waitlist and reminders go out before every stage review.

Recalls go out for the next stage review, the repeat assessment or the imaging follow-up, each message approved by a person. After each visit the signed plan goes home in plain words and each referral, scan and follow-up is tracked until it is done. Before each review, the clinician sees a sourced brief of the athlete, each fact traced to the letter, result or visit it came from. With the athlete's consent, a parent can be given access to letters and messages.

Payments run through the clinic's own Stripe account, with deposits, invoices, memberships for athletes and teams, payment links and insurer invoices. In the UK, blood tests such as iron studies for an endurance athlete are ordered and returned through TDL, each result reaching the athlete with the doctor's own comment and a plain explanation of each marker. The full desk is on the clinic management software page.

One concussion review, start to finish

Take a 17-year-old who plays rugby for his school and a local club, seen in a private sports medicine clinic two days after a tackle in which he took a knock to the head. He had a headache and felt slowed down that evening, and he has mock exams next week. His mother, who is with him, says he was out of it for a moment on the pitch. On questioning, he remembers the whole tackle and never lost consciousness. The clinician works through the office assessment, reads out the symptom scores and explains the graded return to school and sport.

The draft fills the concussion template, with the mechanism, red flags asked and answered, the symptom scores, the examination, a diagnosis of concussion, the plan for a graded return to learning and then sport, and the earliest return to competition at day 21. wai suggests S06.0 beside the line it rests on. The clinician corrects one line, which recorded a brief loss of consciousness from his mother's words, to dazed without loss of consciousness, confirms the code and signs.

Four documents go out. A letter to him and his parents, copied to his GP, sets out the stages and the warning signs. An extenuating circumstances letter goes to his school for the mock exams. With his consent, a short letter to the club coach says he cannot play or train for now and gives the earliest review date, with no other clinical detail. At the front desk, reviews are offered at day 10 and day 21 through a booking link, his mother is given access to the letters with his consent, and reminders go out before each review, each message approved by a person.

The evidence behind wai's method

The note is one part of the day the evidence measures. In a randomised trial of 238 outpatient physicians across 14 specialties at UCLA Health, the ambient scribe with a significant effect cut the time spent writing each note by about 41 seconds, against 18 seconds in usual care.⁶ wai is built on that finding, so it takes on the letters, the replies, the stage reviews and the follow-up as well as the note.

Sports medicine's own consensus puts the record at the centre of the decision. The Bern statement asks for return to sport to be decided collaboratively along a continuum,³ and the UK grassroots guidelines set dated stages for concussion.² A plan written once, with stages and criteria, is what lets the athlete, physio and coach work from the same page.

A draft stays a draft until a person signs it. The Academy of Medical Royal Colleges says the clinician checks every document a scribe produces.⁵ wai holds every draft until the clinician signs it, and every reply until a person at the clinic sends it.

Measured in a working clinic. At The Wellness in London, which runs on wai every day, every clinician has 15 hours a week back, as published in the customer story.⁸

Where to start

Start with new injury assessments for one clinician. Load the clinic's injury template, with fixed fields for side, structure, special tests and the imaging decision, and a concussion template with the stage and dates, and run both for two weeks. Count corrections to side, loss of consciousness and dates, and time the gap from the end of clinic to signed physio letters.

In the second week, add club and school letters with consent recorded, and switch on stage review recalls. Read patient consent for AI scribes, see the MSK page for the wider musculoskeletal day, and browse every specialty on the specialties hub. The scribe itself is on the clinical page.

Frequently asked questions