Orthopaedic Surgeon Template

T&O clerking

A professional Orthopaedic Surgeon template for healthcare professionals.

About this template

Need a clear and concise way to document patient encounters in orthopaedics? This T&O clerking template is designed for orthopaedic surgeons and provides a structured format for recording essential information. It covers key areas like presenting complaints, medical history, examination findings, and treatment plans. This template ensures all critical details are captured, from initial assessment to the plan of care. When used with Heidi, the AI scribe, this template can be automatically populated from your consultations, saving you time and improving the accuracy of your medical documentation. Streamline your workflow and enhance patient care with this efficient documentation tool.

Preview template

Cons on-call: Age / Sex: 67-year-old male Presenting complaints: Right hip pain and inability to weight bear. History of presenting complaints: The patient reports a fall at home two days ago, resulting in immediate right hip pain. He was unable to weight bear following the fall. Pain is described as a sharp, throbbing pain, exacerbated by movement. No previous history of hip pain. Past medical history: Hypertension, managed with medication. Previous left knee replacement. Drug history: Amlodipine 5mg daily, Paracetamol as needed. Allergies: No known drug allergies. Social history: Retired, lives alone. Non-smoker, occasional alcohol use. Investigations: X-ray of right hip performed, showing a displaced fracture of the femoral neck. Review: HR: 88 bpm BP: 140/80 mmHg O/E: Patient in significant pain. Right leg externally rotated and shortened. Tenderness to palpation over the right hip. No open wounds. Neurovascularly intact distally. L/E: Not applicable. Impression: Displaced right femoral neck fracture. Plan: Admit for surgical fixation. Pre-operative bloods and ECG ordered. Discussed risks and benefits of surgery with the patient. Informed consent obtained. Patient to be kept nil by mouth.

Cons on-call: Age / Sex: [Patient’s age and sex] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Presenting complaints: [Presenting complaints or reasons for referral] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) History of presenting complaints: [History and description of current problem, including onset, duration, and progression] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Past medical history: [Relevant past medical and surgical history] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Drug history: [Current medications, including dose and frequency] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Allergies: [Known allergies and reactions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Social history: [Relevant social history, including smoking, alcohol use, occupation, or living situation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Investigations: [Completed investigations and results relevant to this consultation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Review: HR: [Heart rate] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) BP: [Blood pressure] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) O/E: [Findings on examination — inspection, palpation, range of motion, tenderness, deformity, swelling, or neurovascular status] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) L/E: [Details of lower limb examination findings, including sensation, motor function, circulation, or deformities] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Impression: [Working diagnosis or clinical impression] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Plan: [Management plan, including investigations, treatment, referrals, and follow-up instructions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) (For each section above, only include information if it is explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit the section entirely. Never hallucinate, infer, or assume details. Do not state that information is missing—simply omit any section or placeholder without explicit supporting information. Use only the transcript, contextual notes, or clinical note as reference for all content. Use as many lines or paragraphs as needed to capture all relevant information.)

Browse more templates

Use this template