Orthopaedic Surgeon Template

New Patient - Letter [Orthopaedic Surgeon]

A professional Orthopaedic Surgeon template for healthcare professionals.

About this template

Need a clear and concise way to document new patient consultations? This 'New Patient - Letter' template is designed specifically for Orthopaedic Surgeons. It helps streamline the creation of referral letters, ensuring all essential information is captured, from diagnosis and treatment plans to patient history and examination findings. This template is perfect for efficiently communicating with referring physicians. With Heidi, this template can be quickly populated from your clinical notes, saving you time and improving the clarity of your documentation.

Preview template

Diagnosis: - Right shoulder rotator cuff tear Plan: - Advised on conservative management including physiotherapy and activity modification - Discussed the option of corticosteroid injection - Scheduled a follow-up appointment in 6 weeks Thank you for referring John Smith who I reviewed today. John is a 55 year old accountant male who presents with right shoulder pain. He reports the onset of pain approximately 3 months ago, following a fall. The pain is described as a sharp ache, exacerbated by overhead activities and at night. He denies any specific injury. The pain is rated as 7/10 on the visual analogue scale. He has tried over-the-counter analgesics with minimal relief. He reports significant functional limitations, including difficulty reaching overhead and sleeping. He has not tried physiotherapy. John is a non-smoker and drinks alcohol socially. He lives at home with his wife and is independent with all activities of daily living. He has no significant past medical or surgical history. He takes no regular medications and has no known allergies. Physical examination revealed tenderness to palpation over the supraspinatus tendon. Active range of motion was limited in abduction and external rotation. Strength testing revealed weakness in external rotation. The Neer's and Hawkins tests were positive. An MRI scan of the right shoulder was performed in October/2024 at the local imaging centre, which confirmed a full-thickness tear of the supraspinatus tendon. I discussed the diagnosis of a rotator cuff tear with John, explaining the findings of the MRI scan. We discussed both conservative and surgical treatment options. I provided information on physiotherapy and activity modification. I also discussed the option of a corticosteroid injection. We discussed the risks and benefits of each option. John was provided with patient resources on rotator cuff tears. He expressed concerns about the impact of his shoulder pain on his work, which I addressed. Thank you for your ongoing care of John Smith. Please feel free to get in touch if you have any questions or require further information regarding the management plan. Yours Sincerely,

Diagnosis: - [Primary diagnosis including affected side] (List only the main diagnosis with affected side. If there are two distinct pathologies, include both, otherwise focus on the primary condition) Plan: - [Management plan item 1] (Each management plan item should be on its own line with a dash) - [Management plan item 2] - [Management plan item 3] Thank you for referring [patient full name] who I reviewed today. [patient first name] is a [patient age] year old [occupation] [sex] who presents with [chief complaint]. (Include occupation only if explicitly mentioned in the transcript; otherwise omit this term without noting its absence) [detailed history including onset, duration, severity, aggravating/alleviating factors, associated symptoms, functional limitations, previous injuries or trauma, treatments tried and responses. If patient has explicitly denied a therapy when asked about it, state this explicitly, e.g., "She has not tried physiotherapy"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) [combined paragraph incorporating social history, medical and surgical history, current medications, and allergies. Include occupation, home supports, living situation, physical activities or hobbies if mentioned. Write as one cohesive paragraph with no headings or breaks] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) [Physical examination findings including inspection, palpation, range of motion, strength testing, joint stability, deformity, swelling, or tenderness. Then summarise investigations performed, including type (e.g. X-ray, CT, US, MRI), date (month/year), imaging provider name if stated, and key findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) [Summary of treatment discussion including explanation of diagnosis, education, treatment options discussed (surgical and/or non-operative), informed consent, patient resources provided, risks discussed, and any specific concerns addressed during the consult] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Thank you for your ongoing care of [patient_name]. Please feel free to get in touch if you have any questions or require further information regarding the management plan. Yours Sincerely, (Never come up with your own patient details, assessment, plan, interventions, evaluation, or discussion. Use only the transcript, contextual notes or clinical note as a reference. If any information related to a placeholder has not been explicitly mentioned, omit the placeholder completely without noting its absence. Write in full sentences with no section headings except for "Diagnosis:" and "Plan:" at the beginning. Format all diagnosis and plan items on separate lines with a dash. For dates, use month/year format. For imaging providers, include the name exactly as mentioned.)

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