Four ways to reduce orthopedic documentation rework

How workflow adjustments can lighten the documentation burden

Orthopedic, physical and occupational therapists, pain management, and other musculoskeletal clinicians rarely have simple documentation requirements. A single patient encounter may involve reviewing imaging, assessing pain and function, documenting previous procedures, reconciling medications, updating treatment plans, placing orders, and creating detailed follow-up instructions.

That complexity contributes to a growing documentation burden across healthcare. According to a 2024 American Medical Association survey, 22.5% of physicians reported spending more than eight hours per week working in the electronic health record (EHR) outside normal work hours.¹

Meanwhile, the Agency for Healthcare Research and Quality has identified clinical documentation, chart review, orders, workflow fragmentation, and after-hours work among the major drivers of documentation burden.²

Across musculoskeletal care, the goal is not to simply document faster. It is to reduce duplicate work while preserving the clinical detail needed for care continuity, billing accuracy, and patient safety. A few targeted workflow changes can help teams capture information more efficiently within the natural flow of patient care.

Why orthopedic and pain documentation gets complicated fast

Musculoskeletal clinicians often synthesize information from multiple sources during a single patient visit, from imaging and surgical history to therapy progress and functional assessments. Capturing and connecting this information is essential for coordinated, longitudinal care, but it can also increase documentation burden.

Research published in the Journal of the American Academy of Orthopaedic Surgeons found that EHR-related tasks consumed 58% of an orthopedic surgeon's scheduled office day, with note writing representing the largest share of that time.³

When clinicians repeatedly document the same information in different parts of the workflow, administrative work can extend well beyond clinic hours. Here are some strategies that focus on reducing that repetition:

Workflow adjustment 1: Document DURING the encounter, not after

Across musculoskeletal care, clinicians often review imaging, functional findings, or treatment progress with patients during the visit, then spend additional time documenting those same conversations in the medical record. Ambient documentation tools can help reduce this duplication by capturing the discussion while it is already happening. For example, athenaOne® Ambient Notes uses ambient listening and generative AI to create draft note content that clinicians can review, edit, and approve before finalizing documentation.

Soon, musculoskeletal clinicians will be able to leverage athenahealth’s proprietary ambient solution, athenaAmbient, as part of the AI-native clinical encounter. The scribe starts documenting the visit as soon as the AI-native encounter is enabled, giving clinicians the freedom to focus more time on the patient and less time worrying about translating information into the chart.

Whether reviewing imaging, assessing mobility, performing a physical exam, or discussing a treatment plan, musculoskeletal clinicians can stay focused on the patient while ambient documentation captures key clinical details in real time. That means less time reconstructing the visit after hours and more time delivering care.

Emerging research suggests this approach may help reduce documentation burden. A 2026 pilot study involving outpatient orthopedic providers found reductions in note-writing time, after-hours EHR work, and unscheduled documentation activity when ambient AI documentation tools were used.⁴

Similarly, an orthopedic provider at OrthoLoneStar reported a 36 percent reduction in after-hours documentation time, a 12% increase in same-day encounter closure rates, and an average of 3.6 minutes saved per encounter after implementing Ambient Notes.⁵ The provider also reported caring for more patients per day while the documentation burden declined.*

The key principle remains the same regardless of technology: Capture clinical thinking once, during the encounter, rather than recreating it later.

Workflow adjustment 2: Create templates for repeatable procedures and follow-ups

Many musculoskeletal visits follow consistent clinical workflows, making them well suited for structured documentation templates. Standardized templates for procedures, follow-up visits, rehabilitation, injections, bracing, and DME evaluations can help improve efficiency while supporting consistent documentation. Utilizing templates within the EHR can standardize frequently required documentation elements, including:

• Patient history updates
• Procedure details
• Risks and benefits discussions
• Imaging references
• Follow-up recommendations
• Required billing elements

Within athenaOne, configurable documentation workflows and templates can help orthopedic and pain management practices standardize repeatable documentation. And they do that while preserving flexibility for patient-specific findings and clinical decision-making.

When clinicians no longer need to rebuild the same note structure repeatedly, documentation becomes more consistent and may support faster same-day chart closure.

Workflow adjustment 3: Test AI tools that can help pre-encounter preparedness

Preparing for a musculoskeletal visit often means pulling together information from imaging, prior procedures, therapy notes, patient-reported outcomes, and other clinical history. Rather than searching through the chart, AI can quickly surface the most relevant information, helping clinicians spend less time preparing and more time focused on patient care.

Within athenaOne, ChartSync helps bring deduplicated external clinical information into the workflow. Meanwhile, Chart Assistant with Sage™ can help clinicians quickly surface relevant details such as prior imaging, medication history, physical therapy records, and outside consult notes to accelerate chart review.

These tools do not replace clinical judgment or clinician review. Instead, they help reduce the time spent searching through multiple records to locate information that may exist. Clinicians can also have a running dialogue with Sage, the AI assistant, and ask follow-up questions to help get a holistic patient view before delivering care.

Across musculoskeletal care, reducing chart review friction helps clinicians spend less time searching for information and more time focused on patient care.  

Workflow adjustment 4: Build reusable after-visit instructions

Documentation extends beyond the clinical note. Across musculoskeletal care, providers routinely create patient instructions, referrals, rehabilitation plans, follow-up recommendations, and other materials that change little from visit to visit. Technology can automatically align these resources with the reason for the visit, reducing repetitive administrative work while helping ensure patients receive consistent guidance  

Creating reusable after-visit summary templates allows practices to maintain consistency while reducing repetitive administrative work.

Standardized content can be customized for individual patients while ensuring key information is communicated clearly and consistently.

When paired with patient engagement capabilities that provide access to visit summaries, appointment information, and educational materials, these workflows can also help patients better understand their care after the visit. The result is less time spent rewriting common instructions and more time available for patient care.

How to start putting these workflow adjustments into practice

Improving documentation workflows does not require a complete process redesign.

A simple starting approach may include:

1. Identify the three most common visit or procedure types in the practice.
2. Review where documentation is being duplicated.
3. Build or refine templates for recurring workflows.
4. Test utilization of templates and any AI-enabled tools across five to ten encounters.
5. Measure “before and after” documentation accuracy and same-day chart closure rates.
6. Train clinicians, advanced practice clinicians, and support staff on the updated process.

Small workflow improvements often compound over time, particularly in high-volume specialty environments.

Better documentation workflows should protect the clinician-patient conversation

Musculoskeletal providers face complex documentation demands across the care continuum. The goal is not to do less documentation, but to reduce repetitive work so clinicians can spend more time focused on patient care. Whether it's ambient documentation, AI-assisted chart review, structured templates, or automated patient communications, the goal is the same: reducing administrative burden so clinicians can spend more time focused on patients and less time managing documentation.

athenaOne for Orthopedics brings these capabilities together in a single, integrated workflow. From surfacing relevant patient information before the visit to supporting documentation during the encounter and streamlining follow-up workflows afterward, athenaOne helps musculoskeletal providers deliver more connected, efficient care across the patient journey.

As healthcare technology continues to evolve, practices that focus on thoughtful workflow improvements may be better positioned to support same-day chart closure, reduce after-hours administrative work, and preserve the clinician-patient conversation.

Learn more about how athenaOne for Orthopedics can help practices streamline documentation workflows and improve clinical efficiency.