AI Medical Scribe for Orthopedic Surgery & Sports Medicine

Handle 8-12 surgeries per day with same-day documentation. Complete operative notes immediately post-procedure. Leave the OR on time while documenting complex joint replacements, sports medicine procedures, and spine surgeries with the accuracy and detail that workers’ comp and Medicare auditors demand.

OrbDoc transforms orthopedic documentation from evening homework into real-time clinical workflow. Voice-first AI captures detailed physical exams, operative notes, and post-op documentation while your gloves are still on, reducing after-hours charting while improving documentation quality and coding accuracy.

Orthopedic Workflow Challenges

Orthopedic surgeons and sports medicine physicians face unique documentation challenges that traditional EHR templates fail to address. The combination of high surgical volume, complex physical examinations, and procedure-intensive workflows creates a perfect storm of documentation debt.

Operative Note Completion Delays

High-volume orthopedic surgeons perform 8-12 procedures daily across ASCs and hospital ORs. Each operative note requires detailed documentation of approach, hardware specifications, complications, and post-operative plans. Traditional dictation or template-based systems mean surgeons spend 2-3 hours after their last case completing operative notes, often working until 8-9 PM despite the OR closing at 5 PM.

This documentation burden creates dangerous delays. Medicare requires operative notes within 24 hours. Workers’ comp cases demand extensive procedural detail for claim justification. Yet the pressure to maintain surgical volume means many orthopedists defer documentation until late evening, increasing burnout risk and reducing time with family. Leave the OR on time by documenting while the case is fresh.

High-Volume Clinical Demands

Orthopedic clinics operate at exceptional velocity. A typical sports medicine clinic schedules patients every 10-15 minutes, with surgeons managing everything from simple ankle sprains to complex post-operative follow-ups. Each patient requires comprehensive physical examination documenting multiple joint systems, range of motion measurements, strength testing, and special tests without slowing the exam flow.

Traditional EHR documentation requires clicking through dozens of templates and dropdown menus that interrupt the physical examination. The pressure to maintain productivity means many orthopedists defer documentation until after clinic, spending 2-3 hours each evening completing notes. This creates documentation fatigue and reduces the quality of physician-patient interaction during the visit itself.

Physical Exam Documentation Complexity

Orthopedic physical examinations are inherently detailed and systematic. A knee exam alone might include inspection for effusion, palpation of joint lines and bony landmarks, range of motion in multiple planes, ligamentous stability testing (Lachman, anterior drawer, valgus/valgus stress), meniscal testing (McMurray, Thessaly), and functional assessments. Each finding must be documented with specific measurements and laterality.

Traditional templates force providers into rigid documentation structures that don’t match clinical workflow. You might examine the hip, then the knee, then return to the hip for special tests based on your findings. But EHR templates demand linear progression through predetermined fields. This creates cognitive friction between how you practice medicine and how you’re forced to document it.

Bilateral examinations compound the complexity. Comparing right versus left findings is clinically essential but documentarily burdensome. Templates require separate entries for each side, forcing providers to toggle between sections or copy-paste with manual editing. The risk of documentation errors - mixing up laterality or copying inappropriate findings - increases with template complexity.

Procedure Documentation Requirements

Orthopedic practice is procedure-intensive. Joint injections, aspirations, fracture reductions, splinting, and casting occur frequently throughout the day. Each procedure requires detailed documentation for billing justification, workers’ comp claim support, and medicolegal protection.

Procedure notes must capture indication, consent documentation, anatomical approach, technique specifics, medications used with lot numbers and dosages, patient response, and post-procedure instructions. Creating comprehensive procedure notes in traditional EHRs requires navigating multiple screens and fields while maintaining sterile technique and patient positioning.

The billing implications are significant. Inadequate procedure documentation leads to claim denials, particularly for higher-complexity injections requiring image guidance or multiple anatomical approaches. Workers’ comp cases require detailed mechanism of injury documentation, work-relatedness assessment, and functional limitations for claim justification. E/M coding depends on documenting medical decision-making complexity, but templates rarely capture the nuanced clinical reasoning behind choosing surgical versus conservative management.

Post-Operative Documentation Volume

Surgical orthopedists manage extensive post-operative visit schedules. Each post-op visit requires documenting wound status, range of motion progress, pain levels, complications, rehabilitation advancement, and return-to-activity decisions. The documentation burden multiplies across the 6-12 week post-operative period with multiple follow-up visits per patient.

Capturing progress objectively matters for outcomes tracking and complication identification. But clicking through identical templates for routine post-op visits creates documentation fatigue. Providers need efficient ways to document normal healing while flagging concerning findings that require intervention.

Physical Exam Documentation Made Natural

OrbDoc transforms orthopedic physical exam documentation from a structured data entry task into natural clinical narration. The AI understands orthopedic terminology, anatomy, and examination sequences, allowing providers to document exams exactly as they perform them.

Voice-First Range of Motion Documentation

Simply speak your findings as you examine the patient. “Right shoulder forward flexion 170 degrees, abduction 160 degrees, external rotation 80 degrees, internal rotation to T8. Left shoulder full range of motion.” OrbDoc captures these measurements accurately, formats them appropriately, and structures them for billing documentation.

The AI recognizes standard orthopedic terminology and measurement conventions. You can speak in your natural clinical language - “FROM” for full range of motion, “WNL” for within normal limits, or specific degree measurements. The system understands bilateral comparisons and automatically structures findings by joint and movement plane.

Complex multi-joint examinations become effortless. Examining a throwing athlete’s shoulder, elbow, and wrist in sequence? Narrate your findings continuously without stopping to document. OrbDoc maintains anatomical organization while preserving your clinical workflow. The AI recognizes when you return to a previously examined joint for additional testing and integrates the findings appropriately.

Special Test Documentation

Orthopedic diagnosis depends on special tests with specific names and interpretations. OrbDoc recognizes hundreds of orthopedic special tests across all joint systems. Simply state the test name and result: “Lachman test positive for increased anterior translation. Anterior drawer negative. McMurray test positive medial compartment with clicking at 45 degrees flexion.”

The system understands test-specific terminology and normal versus abnormal findings. Positive versus negative interpretations are captured correctly, along with qualitative descriptors like “trace,” “1+,” “moderate,” or “severe.” This ensures your documentation accurately reflects clinical findings without ambiguity.

Bilateral comparison documentation is automatic. “Right shoulder Neer test positive, Hawkins positive, empty can positive. Left shoulder impingement testing negative.” OrbDoc structures these findings clearly by side, making asymmetry obvious in the documentation. This matters for both clinical decision-making and demonstrating examination thoroughness to payers.

Strength and Neurovascular Assessment

Motor strength testing requires systematic documentation across multiple muscle groups and nerve distributions. Speak your findings naturally: “Right lower extremity strength 5/5 hip flexion, extension, abduction, and adduction. Knee extension 5/5, knee flexion 4/5. Ankle dorsiflexion 5/5, plantarflexion 5/5. Extensor hallucis longus 5/5.”

The AI understands standard strength grading scales and muscle group terminology. It organizes findings by anatomical region and correlates them with nerve root distributions when relevant. For patients with weakness, additional context like “secondary to pain” or “due to surgical precautions” is captured and associated correctly.

Neurovascular documentation is equally straightforward. “Dorsalis pedis and posterior tibial pulses 2+ bilaterally. Sensation intact to light touch in L4, L5, and S1 distributions. No saddle anesthesia.” The system recognizes vascular examination findings, dermatomal patterns, and concerning findings that require specific documentation for medical decision-making complexity.

Gait and Functional Assessment

Functional assessment documentation matters for demonstrating severity and tracking improvement. Describe what you observe: “Patient ambulates with antalgic gait favoring the right lower extremity. Unable to heel walk on the right. Toe walking intact bilaterally. Single leg stance time 3 seconds on the right versus 30 seconds on the left.”

OrbDoc captures qualitative gait descriptions and quantitative functional measurements. The documentation reflects both current impairment and comparison to normal function, supporting medical necessity for interventions. For athletes, sport-specific functional testing is documented naturally: “Hop test 70% symmetry. Single leg squat demonstrates knee valgus collapse on the right.”

Sports Medicine Clinic Results

High-volume sports medicine practices were seeing 40-50 patients daily and charting 2-3 hours every evening. Exhausted from documentation, not patient care.

After implementation:

• Chart 1 hour after clinic, not 2-3 hours
• Document shoulder exams during the exam, not from memory hours later
• Look at the patient during physical exams, not the computer screen
• Capture detailed range-of-motion findings that support proper E/M coding
• Leave the clinic when the last patient leaves

Sports medicine physicians dictate complex physical exams during the examination itself. Shoulder exams previously requiring extensive template clicking now documented in under a minute through continuous narration. No more choosing between eye contact with the athlete or complete documentation.

Procedure Documentation in Real-Time

Orthopedic procedures require immediate, detailed documentation that captures technique, medications, and patient response. OrbDoc enables real-time procedure note creation through voice narration, eliminating the need for post-procedure documentation sessions.

Joint Injection Documentation

Speak your procedure note during or immediately after the injection: “Left knee intra-articular injection performed. Informed consent obtained. Timeout performed confirming correct patient, site, and side. Superolateral approach using sterile technique with chlorhexidine prep. 20 gauge needle inserted, 35cc serosanguinous fluid aspirated and sent for cell count, crystal analysis, gram stain and culture. Joint then injected with 80mg Kenalog and 5cc 1% lidocaine. Patient tolerated procedure well without complications. Post-procedure instructions provided regarding activity restrictions and warning signs.”

OrbDoc structures this narration into a compliant procedure note with all required elements. Medication names, dosages, and lot numbers are captured accurately. The documentation supports both medical necessity and procedure complexity for billing purposes.

Fracture Reduction and Splinting

Reduction procedures require documenting pre-reduction neurovascular status, reduction technique, post-reduction alignment, and immobilization details. Narrate the procedure: “Closed reduction right distal radius fracture performed. Pre-reduction neurovascular exam intact with 2+ radial pulse and normal sensation. Conscious sedation achieved with fentanyl 100mcg and midazolam 2mg. Longitudinal traction applied with counter-traction. Dorsal angulation corrected with volar displacement of distal fragment. Post-reduction films show acceptable alignment with less than 2mm radial shortening and 5 degrees volar tilt. Sugar tong splint applied. Post-reduction neurovascular exam unchanged.”

The AI captures all critical elements including pre- and post-procedure assessments, sedation documentation, technique specifics, and radiographic findings. This comprehensive documentation supports billing for reduction procedures while providing medicolegal protection.

Casting and Splinting Documentation

Even routine immobilization requires proper documentation: “Short leg cast applied for right ankle fracture. Stockinette and cast padding applied from toes to below knee. Four-inch fiberglass casting material used. Ankle positioned in neutral dorsiflexion. Patient instructed on cast care, elevation, ice application, and warning signs of compartment syndrome. Return precautions reviewed.”

OrbDoc structures these findings appropriately while capturing patient education and safety counseling that demonstrates thoroughness of care.

Pre-Operative and Post-Operative Documentation

Surgical orthopedists manage extensive pre-operative evaluations and post-operative follow-up visits. OrbDoc streamlines documentation across the surgical episode.

Pre-Operative Clinic Notes

Pre-operative visits establish surgical indication and document informed consent discussions. Speak your medical decision-making: “Conservative management has failed including six months physical therapy, NSAIDs, and activity modification. MRI demonstrates full-thickness rotator cuff tear involving supraspinatus and infraspinatus. Patient desires surgical intervention to return to recreational tennis. Risks, benefits, and alternatives to arthroscopic rotator cuff repair discussed extensively including infection, stiffness, re-tear, need for further surgery. Patient demonstrates understanding and wishes to proceed.”

This narration creates comprehensive documentation supporting medical necessity while capturing informed consent discussions that protect against medicolegal risk.

Post-Operative Progress Notes

Post-op visits track healing progression and rehabilitation advancement. Efficient documentation captures key findings: “Post-op day 14 right shoulder arthroscopic rotator cuff repair. Surgical incisions clean, dry, and intact. No erythema or drainage. Right shoulder range of motion per protocol: passive forward flexion 90 degrees, passive external rotation 20 degrees. Pain well controlled. Advancing to phase two rehabilitation. Return in four weeks.”

OrbDoc maintains continuity across post-operative visits, making it easy to track progression and identify complications requiring intervention. The documentation supports appropriate E/M coding while reducing the time burden of repetitive post-op notes.

Ready to transform your orthopedic documentation workflow? Download OrbVoice on the Apple App Store and experience voice-first AI scribing designed for high-volume orthopedic and sports medicine practice.