Orthopaedic Surgeon Template

Ortho On Call Review

A professional Orthopaedic Surgeon template for healthcare professionals.

About this template

Streamline your orthopaedic on-call documentation with our 'Ortho On Call Review' template. This essential tool for orthopaedic surgeons and their teams helps capture critical patient information during urgent consultations. From detailed histories of presenting complaints and physical examination findings to X-ray interpretations and comprehensive management plans, this template ensures no detail is missed. Ideal for documenting acute injuries like fractures, it provides a structured format for consultants and registrars. When used with Heidi, our AI medical scribe, this template will intelligently populate sections based on your clinical discussions, ensuring accurate and efficient record-keeping for every orthopaedic emergency.

Preview template

Consultant on call: Dr. Eleanor Vance Consultant of the week: Dr. Thomas Kelly Alice Smith 45 Female Date: 01 November 2024 Hospital Number: AS789012 Issues/Diagnosis: Right Distal Radius Fracture, Colles' type Date of injury: 30 October 2024 PMH/PSH: Hypertension (controlled with medication), no previous surgeries. DH: Lisinopril 10mg OD. NKDA (No Known Drug Allergies). SH: Lives with husband, non-smoker, occasional social alcohol, works as an administrative assistant. HPC: * Patient presented to A&E after a fall onto an outstretched right hand yesterday evening. * Experienced immediate pain and swelling in the right wrist. * Unable to move wrist since injury. * No neurovascular deficits reported by patient. * Denies loss of consciousness or head injury. On Examination: Right wrist: * Obvious deformity (dinner fork deformity) noted. * Significant swelling and tenderness over the distal radius. * Reduced range of motion due to pain. * Intact sensation to light touch in median, ulnar, and radial nerve distributions. * Capillary refill time less than 2 seconds in all digits. * Radial pulse palpable and strong. XR: AP and lateral views of the right wrist show a complete transverse fracture of the distal right radius with dorsal displacement and angulation, consistent with a Colles' fracture. No evidence of carpal bone fracture or dislocation. Ulnar styloid intact. Plan: 1. Discuss with patient about closed reduction under local anaesthetic in ED or theatre. 2. Proceed with closed reduction and casting. If reduction is unstable, consider k-wire fixation. 3. Arrange for post-reduction X-rays to confirm satisfactory alignment. 4. Refer to fracture clinic for follow-up in one week with new X-rays. 5. Provide patient with cast care instructions and pain management advice (e.g., paracetamol and ibuprofen).

Consultant on call: [consultant on call name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). Consultant of the week: [consultant of the week name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [patient full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [patient age] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [patient gender] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Date: [current date and time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Hospital Number: [patient hospital number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Issues/Diagnosis: [identified issues or diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Date of injury: [date of injury] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PMH/PSH: [past medical and surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) DH: [drug history, including current medications and allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) SH: [social history, including relevant lifestyle factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) HPC: [history of the presenting complaint, including onset, duration, character, and associated symptoms. Use bullet points] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) On Examination: [findings from the physical examination performed on the patient. Start with a heading of the region and laterality being examined e.g. right lower leg, followed by a new line and bullet points for each examination finding] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) XR: [summary and interpretation of X-ray findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: 1. [first point of the management plan, including investigations, treatments, referrals, or follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 2. [second point of the management plan, including investigations, treatments, referrals, or follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 3. [third point of the management plan, including investigations, treatments, referrals, or follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 4. [any additional points of the management plan, including investigations, treatments, referrals, or follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Continue numbering.)

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