Orthopaedic Surgeon Template

Orthopaedic assesment and plan

A professional Orthopaedic Surgeon template for healthcare professionals.

About this template

Need a clear and concise way to document your orthopaedic assessments? This Orthopaedic Assessment and Plan template is designed for orthopaedic surgeons to efficiently record patient information. It covers essential areas like patient history, examination findings, investigations, assessment, and a detailed plan. This template helps streamline your note-taking process, ensuring all critical details are captured. With Heidi, this template can be quickly populated from your consultations, saving you time and improving the accuracy of your documentation. Easily create comprehensive clinical notes with this user-friendly template.

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Patient: 62-year-old male with a history of right knee pain. History: The patient presents with a chief complaint of right knee pain that has been worsening over the past six months. The pain is described as a dull ache, exacerbated by weight-bearing activities such as walking and climbing stairs. He reports stiffness in the morning that lasts for approximately 30 minutes. The pain is partially relieved by rest and over-the-counter pain medication. There is no history of trauma. The pain significantly impacts his ability to participate in his usual activities, including his daily walks and playing with his grandchildren. Past Medical History: - Hypertension - Hyperlipidemia - Previous left knee arthroscopy Examination: On examination, the patient is ambulatory with an antalgic gait. There is mild swelling and tenderness to palpation over the medial joint line of the right knee. Range of motion is limited to 0-100 degrees of flexion. A varus deformity is noted. The McMurray test is negative. The Lachman test is negative. The patient has a positive Thessaly test. Investigations: X-rays of the right knee were obtained and demonstrate moderate osteoarthritis with joint space narrowing in the medial compartment. Assessment: Right knee osteoarthritis. Plan: - Discussed conservative management options, including weight loss, activity modification, and physical therapy. - Prescribed a course of physical therapy to improve range of motion and strengthen the muscles around the knee. - Recommended the use of a knee brace for support during activities. - Scheduled a follow-up appointment in six weeks to assess the patient's response to treatment. - Discussed the possibility of future surgical intervention, such as a total knee replacement, if conservative measures fail.

Patient: [patient's age, gender, and other relevant demographic details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single sentence.) History: [details of the patient's presenting complaints, including duration, character, relieving/aggravating factors, associated symptoms, and impact on daily activities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Past Medical History: [list of the patient's significant past medical conditions, including chronic diseases and previous surgeries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list using a hyphen for each item.) Examination: [findings from the physical examination, including specific body parts examined, observations, palpation findings, range of motion, and results of special tests] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Investigations: [results of diagnostic investigations, including imaging, laboratory tests, or other relevant studies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Assessment: [clinical diagnosis or differential diagnoses based on the history, examination, and investigation findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single sentence.) Plan: [proposed management plan, including further investigations, medical treatments, surgical interventions, referrals, and follow-up arrangements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list using a hyphen for each item.) (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, depending on the format, as needed to capture all the relevant information from the transcript.)

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