Orthopedics Documentation Challenges
RxNote understands the unique documentation needs of orthopedics
Detailed Physical Exams
Orthopedic exams require precise documentation of ROM, strength testing, special tests, and neurovascular status.
Surgical Documentation
Pre-op, intra-op, and post-op documentation demands are extensive and time-sensitive.
Imaging Correlation
X-ray, MRI, and CT findings need to be accurately referenced and correlated with clinical findings.
Orthopedics AI Scribe Features
Specialized documentation tools for orthopedics encounters
MSK Exam Documentation
Captures range of motion, strength grades, special tests (Lachman, McMurray, etc.), and neurovascular status.
Surgical Consultation Notes
Streamlined documentation for surgical consultations including indications, risks, and informed consent discussions.
Imaging Correlation
Documents X-ray, MRI, and CT findings discussed during the encounter with proper terminology.
Post-Op Follow-Up Notes
Templates for wound checks, hardware assessments, and rehabilitation progress documentation.
Rehabilitation Plans
Captures physical therapy recommendations, activity restrictions, and return-to-work/sport plans.
Workers Comp Documentation
Comprehensive documentation meeting workers' compensation reporting requirements.
How It Works
Get started in three simple steps
Examine Your Patient
Perform your MSK exam and describe your findings as usual.
AI Captures MSK Details
RxNote captures ROM measurements, special test results, and imaging correlations.
Generate Complete Notes
Review your orthopedic note with structured exam findings and treatment plans.
Why Orthopedics Providers Choose RxNote
- Precise ROM and special test documentation
- Surgical consultation notes in minutes
- Post-op follow-up documentation streamlined
- Imaging findings accurately referenced
- HIPAA-compliant with enterprise-grade security
- Workers' compensation documentation support
Sample Orthopedics Note
See how RxNote generates structured documentation for orthopedics encounters
Subjective
42 y/o male construction worker with right knee pain x 6 weeks after twisting injury. Reports giving way, swelling, and difficulty with stairs. Failed conservative treatment with NSAIDs and PT.
Objective
Right knee: moderate effusion, full extension, flexion to 125°. Positive Lachman test (Grade 2), positive pivot shift. Negative McMurray. NV intact. MRI: complete ACL tear, lateral meniscus intact.
Assessment
Complete ACL tear, right knee (S83.511A). Failed conservative management.
Plan
1) Discussed surgical vs non-operative options. 2) Patient elects ACL reconstruction. 3) Pre-op labs and clearance. 4) Surgery scheduled in 3 weeks. 5) Continue PT for pre-hab.