Surgeon Template

Surgical Consultation and Assessment Note

A professional Surgeon template for healthcare professionals.

About this template

Streamline your surgical consultations with our 'Surgical Consultation and Assessment Note' template, expertly designed for general surgeons, orthopaedic surgeons, and other surgical specialists. This comprehensive template guides you through documenting key aspects of patient assessment, from the initial referral and presenting complaint to detailed clinical examination findings and a robust management plan. Capture crucial information on relevant history, investigations reviewed or ordered, and your impression with differential diagnoses. Ideal for both outpatient clinics and inpatient assessments, this template ensures all vital surgical considerations are meticulously recorded. When used with Heidi, this template intelligently extracts and organises information from your clinical dialogue, making documentation efficient and thorough, helping you focus more on patient care and less on paperwork.

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Surgical Consultation and Assessment Note Referral Reason and Presenting Complaint: Patient referred by General Practitioner for evaluation of right inguinal swelling. Patient reports a progressively enlarging, reducible lump in the right groin for the past 6 months. It becomes more prominent with coughing or straining and is associated with a dull ache, particularly towards the end of the day. No fever, nausea, vomiting, or changes in bowel habits. Initial management involved over-the-counter analgesia with paracetamol, which provided minimal relief. Patient works as a forklift operator, and the discomfort is now affecting his work performance. Relevant History: Past Medical History: Controlled hypertension, diagnosed 5 years ago, managed with Amlodipine 5mg OD. No history of diabetes, HIV, or TB. No previous surgical history. Family history is unremarkable for hernias or significant surgical conditions. Medication List: Amlodipine 5mg OD. No known allergies. Social History: Smokes 5-10 cigarettes/day for 15 years, occasional alcohol consumption (socially). Lives in a rented flat. Type of employment: Forklift operator (manual labour). Clinical Examination Findings: On examination, a reducible, non-tender, ovoid swelling noted in the right inguinal region, approximately 4x3 cm. Impulse felt on coughing. No discoloration or warmth of the overlying skin. Left inguinal region is unremarkable. Abdomen is soft, non-tender, with no other masses or organomegaly. Bowel sounds are normal. Peripheral pulses are palpable and symmetrical. Investigations Reviewed or Ordered: No investigations reviewed prior to this consultation. Ordered: Full Blood Count (FBC), Urea & Electrolytes (U&E), Coagulation profile (PT/INR, APTT) to be done at NHLS labs. Referral for ultrasound of the right inguinal region to confirm diagnosis and assess contents. Impression and Differential Diagnosis: Impression: Right reducible inguinal hernia. Differential Diagnosis: Femoral hernia, saphena varix, enlarged lymph node, lipoma. Diagnostic certainty for inguinal hernia is high given clinical presentation and examination findings. Management Plan: Discussed surgical repair with the patient. Patient keen for intervention due to work-related discomfort. Plan: 1. Investigations as ordered (FBC, U&E, Coags, USS Right Inguinal Region). 2. Review results once available. 3. List for elective open hernia repair at regional hospital. 4. Patient education provided regarding the nature of the hernia, surgical procedure, and potential risks/benefits. Advised to reduce straining and avoid heavy lifting until surgery. 5. Follow-up: To be reviewed in surgical outpatient clinic in 4 weeks with investigation results for pre-operative assessment and consent. Date of consultation: 1 November 2024

Surgical Consultation and Assessment Note Referral Reason and Presenting Complaint: [document the reason for referral, symptoms, duration, progression, and previous treatments attempted. Include referrals from primary health clinics, district hospitals, or private GPs if relevant. Note symptom evolution such as pain, swelling, or impaired function and any initial management such as analgesia or physiotherapy] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Relevant History: [include past medical and surgical history including conditions like hypertension, HIV, TB, diabetes, or previous procedures at state or private hospitals. Include family history (if relevant to surgical risk), medication list (including ART or chronic meds), known allergies, and social history such as tobacco/alcohol use, housing, or type of employment (e.g. physical/manual labour, domestic work)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Clinical Examination Findings: [record physical findings relevant to surgical assessment such as site-specific tenderness, swelling, hernias, masses, neurological signs, limb function, or wound characteristics. Include any observations made during outpatient clinic or bedside assessment] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Investigations Reviewed or Ordered: [summarise reviewed X-rays, ultrasounds, blood work, or referrals for additional imaging or specialist review. Include context such as public hospital radiology, NHLS labs, or point-of-care testing done during clinic visit] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Impression and Differential Diagnosis: [document working diagnosis and alternate considerations based on findings. Include diagnostic certainty, suspected pathology (e.g. abscess, bowel obstruction, malignancy), and relevance to surgical candidacy] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Management Plan: [outline next steps including referral for surgery at higher level of care (e.g. regional/tertiary hospital), surgical listing, additional investigations (e.g. CT scan), conservative management (e.g. wound care), or patient education. Include follow-up timing or referrals for social support if applicable] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points as needed to capture all the relevant information from the transcript.)

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