AI Scribe for Orthopedic Surgery
Transcribe Health drafts your clinic, injection, and post-op notes while you examine the patient, so the range-of-motion numbers and special tests are on the page before you move to the next room.
Photo: Usman Yousaf / Unsplash
Orthopedic documentation, from clinic to the procedure room
Orthopedic clinic moves fast and every note is physical. A knee patient needs range of motion, ligament and meniscus tests, and a read of the standing films. A shoulder needs Neer, Hawkins, and rotator-cuff strength. A spine follow-up needs a neuro exam and the MRI level. Each of those has numbers and named tests that have to land in the note, and by the time you have seen the fourth patient of the hour, that is a lot to hold.
A good share of the day is procedural. A knee gets aspirated and injected, a trigger finger gets a steroid shot, a fracture gets reduced and splinted. Those need a real procedure note: the joint, the approach, the medication and volume, the aftercare. That is separate from the clinic note but often happens in the same visit.
Transcribe Health listens to the visit, or to your narration during a procedure, and drafts a note that puts the detail where it belongs: degrees of flexion, a positive McMurray, the fracture pattern you described, the 40 mg of Kenalog you injected. You read it and sign. Nothing is filed without you.
Documentation Challenges in Orthopedic Surgery
- 1
Keeping up with a high-volume clinic where 30 or more patients a day each need a distinct musculoskeletal note
- 2
Capturing a full exam in a note: range of motion in degrees, strength grading, and the special tests (Lachman, McMurray, Neer, Hawkins) that carry the diagnosis
- 3
Correlating your read of an X-ray, MRI, or fracture pattern with the exam, and writing up the injections and bedside procedures with the detail billing requires
How Transcribe Health Helps Orthopedic Surgery
Musculoskeletal Exam Notes
Records range of motion in degrees, strength grades, and the special-test results you call out as you examine each joint.
Injection and Procedure Documentation
Turns your narration during a joint injection or aspiration into a structured procedure note with site, approach, and what you used.
Fracture and Imaging Correlation
Puts your read of the X-ray or MRI into the note next to the exam, so the plan reads with the finding that drove it.
An orthopedic note, captured in real time
An abridged clinic note from a knee osteoarthritis evaluation and injection, drafted the way you would see it before signing.
64-year-old woman with 8 months of medial-sided right knee pain, worse with stairs and after prolonged standing. No locking or giving way. Reports morning stiffness lasting about 15 minutes. Tried acetaminophen and a course of naproxen with partial relief. No recent trauma. Prior left knee pain, never treated.
Antalgic gait favoring the right. Right knee: small effusion, no warmth or erythema. Range of motion 5 to 120 degrees, compared with 0 to 135 on the left. Tenderness over the medial joint line. McMurray positive medially, Lachman negative, no varus or valgus laxity. Quadriceps strength 5/5. Distal pulses intact, sensation normal. Weight-bearing AP and lateral radiographs reviewed today: medial compartment joint-space narrowing, subchondral sclerosis, and small osteophytes, Kellgren-Lawrence grade 3.
1) Primary osteoarthritis of the right knee, medial compartment, Kellgren-Lawrence grade 3, symptomatic. 2) Degenerative medial meniscus tear suspected on exam, not limiting at this time.
Discussed the diagnosis and options. Right knee intra-articular corticosteroid injection performed today under sterile technique via a superolateral approach: 40 mg triamcinolone acetonide with 5 mL of 1% lidocaine, no complications, patient tolerated it well. Continue naproxen as needed with food. Home quadriceps-strengthening program and referral to physical therapy. Weight management discussed. Return in 6 weeks; if pain recurs, consider hyaluronic acid injection and discuss timing of arthroplasty.
Illustrative example. Not a real patient encounter.
Built for orthopedic coding and your EMR
Notes capture the exam findings, the data you reviewed, and the procedure detail that back up your E/M level and a joint injection's medical necessity. That is the detail auditors look for, and the first thing to slip when clinic is running behind.
- 99204 / 99205New-patient office visit, moderate to high complexity
- 99214 / 99215Established-patient office visit, moderate to high complexity
- 20610Arthrocentesis, aspiration or injection of a major joint (knee, shoulder, hip)
- 20605Arthrocentesis, aspiration or injection of an intermediate joint (elbow, wrist, ankle)
- 20550Injection of a tendon sheath or ligament (trigger finger, plantar fascia)
- 29075Application of a short-arm cast for closed fracture care
- M17.11Unilateral primary osteoarthritis, right knee
- M75.100Unspecified rotator cuff tear or rupture, not traumatic, unspecified shoulder
- M23.221Derangement of medial meniscus from old tear, right knee
- S82.101AUnspecified fracture of upper end of right tibia, initial encounter
- M54.5Low back pain
Fits the workflow you already have
Drafts drop into the major EMRs orthopedic groups run on: Epic, Oracle Health (Cerner), and athenahealth. You get whatever note type you are working in, a clinic evaluation, an injection procedure note, or a fracture follow-up. It writes up the imaging read you dictate. It does not open your PACS or read the X-ray for you; you make the call and it records what you said.
What's Happening in Orthopedic Surgery
AAOS Study: Prior Authorization Does Not Reduce Costs, Delays Care
A new study found that prior authorization does not reduce costs for total hip arthroplasty but does delay patient care. The process increases administrative burden with little consideration of evidence-based treatment timing.
AI-generated clinical documentation that captures medical necessity language at the point of care can streamline prior auth submissions and reduce approval delays.
Read moreCMS Prior Authorization Reform: Decision Windows Cut from 14 to 7 Days
CMS finalized its Prior Authorization Reform Rule cutting payer decision windows from 14 to 7 calendar days and mandating electronic prior authorization for all Medicare Advantage and commercial payers.
Electronic prior auth mandates require clean, structured clinical documentation at first submission. AI transcription that captures operative details and clinical justification helps meet these requirements.
Read more94% of Physicians Say Prior Authorization Causes Care Delays
According to the AMA, 94% of physicians report prior authorization causes care delays, and 78% say delays lead patients to abandon recommended treatment. Orthopedic procedures are disproportionately affected.
Comprehensive clinical documentation generated during the encounter, including imaging findings, failed conservative treatments, and functional limitations, provides the evidence needed for faster prior auth approvals.
Read moreOrthopedic AI scribe questions
Does it capture exam detail like range of motion and special tests?
Can it document injections and bedside procedures?
Does it read my X-rays and MRIs?
How is patient information protected?
Will it help with coding and audit defensibility?
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