Osteoporosis is a condition that decreases bone density and is more commonly found in elderly women due to estrogen depletion. The decrease in bone density puts patients at risk for fragility fractures, or fractures with minimal impact, which can drastically alter patients’ lives. Primary prevention of these fractures is the goal with pharmacologic therapy for osteopenia or osteoporosis. There are many treatment options for osteoporosis and most are considered cost effective for patients with high fracture risk due to decreased bone density. Treatment decisions for osteopenia or osteoporosis are now based upon a fracture risk assessment tool in addition to T-score values. Studies have demonstrated that adherence to pharmacologic therapy to decrease fracture risk and maintain bone density is an issue with the majority of patients. Most patients are not staying on treatment for greater than one year for a variety of reasons. A practice improvement project was conducted at an internal medicine private practice clinic that serves 10,000 patients in a Midwestern community. The project included retrospective chart reviews and key informant interviews in order to gain expanded knowledge of the issue and provide recommendations for improvement. Results showed inconsistent documentation of patient treatment preferences and provider treatment decisions. Additional areas for improvement included patient and provider follow up of treatment decisions as well as patient education regarding the disease process and benefits of treatment. Results and recommendations for improvement were disseminated to providers at the clinic with feedback solicited. An electronic medical record change was implemented in order to improve documentation of treatment decisions regarding elevated fracture risk. The results of the project may not be transferrable due to small sample size and area of focus at one Midwest clinic. However, themes regarding clinical decision-making and documentation of osteoporosis treatment emerged that likely exist at other primary care clinics. Further research is needed in order to evaluate effectiveness of electronic medical record intervention at the clinic. Other opportunities for further research involve expanding the topic to larger healthcare organizations and other areas of the country for comparison.