Orthopaedic New Consultation

"It was a pleasure to review you in clinic today. This letter summarises the key points from our consultation:" [Reason(s) for consultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences and include details such as musculoskeletal concerns or symptoms.) - [Patient age and occupation and exercise activity] (State the patient’s age in years and describe occupation and exercise activity. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.Write in paragraphs of full sentences) [Social history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of complete sentences and include occupational background, physical activity levels, and relevant lifestyle factors.) - [History of the presenting complaint(s)] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences and include details such as onset, location of pain, radiation of pain, sleep disturbance, stiffness, subluxation, dislocation, severity, aggravating and alleviating factors, associated symptoms, neurological symptoms and prior events.) - [Current issues or reasons for visit] (Write in paragraphs of full sentences. Include the presenting complaints or concerns as described by the patient. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [Symptom characteristics] (Write in paragraphs of full sentences. Describe the duration, timing, location, quality, severity, or context of the presenting issue. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [Symptom modifiers or self-management] (Write in paragraphs of full sentences. List any factors that improve or worsen symptoms, including any attempted treatments or remedies. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [Symptom progression] (Write in paragraphs of full sentences. Explain how symptoms have changed or evolved since onset. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [Previous episodes] (Write in paragraphs of full sentences. Detail any similar prior events, their timing, management, and outcomes. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [Impact on daily activities] (Write in paragraphs of full sentences. Describe how symptoms affect the patient’s daily functioning, work, or lifestyle. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [Associated symptoms] (Write in paragraphs of full sentences. Include any additional focal or systemic symptoms accompanying the primary complaint including duration. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [Previous treatments, previous physiotherapy, previous osteopathy, previous injections and responses] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences and include prior interventions and outcomes.) _Past Medical and Surgical History_: [Relevant past medical and surgical history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list and include history such as musculoskeletal disorders, prior surgeries, hospitalisations, and relevant outcomes.) _Medications_: [Current medication use] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list and include pain medications, anti-inflammatories, supplements, and other relevant drugs.) [Medication information sources] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in sentence format.) [Allergies] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list and include allergies to medications, materials, or substances relevant to orthopaedic care.) _Examination_: [Vital signs] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) [Musculoskeletal examination findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs and full sentences include findings on inspection, palpation, range of motion, strength, joint stability, and signs of inflammation or deformity.) [Neurovascular examination findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet points and include assessment of nerve function and vascular status.) _Investigations_: [Investigation findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet points and include relevant imaging and laboratory results.) _Management Plan_: [Name of orthopaedic issue] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Investigations planned] (List any diagnostic tests to be ordered. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.Write in paragraphs and complete sentences) [Treatment planned] (Document any medications, therapies, or treatments recommended. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [Planned non-surgical treatments] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs and complete sentences including therapies, medications, or conservative management strategies.) - [Planned surgical treatments] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs and complete sentences and include details such as procedure type, fixation method, care setting, and medication protocols. - [list specific risks and complications such as bleeding, infection, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs and complete sentences.) - [describe immediate post-operative care instructions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs and complete sentences.) - [outline typical recovery timeline or stages] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs and complete sentences.) - [mention planned follow-up appointments, wound care, or rehabilitation instructions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs and complete sentences.) - [Pre-operative preparation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs and complete sentences and include preparatory measures and instructions.) - [Post-operative care plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs and complete sentences and include rehabilitation, follow-up, and symptom management strategies.) - [Referrals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs and complete sentences and include specialist or allied health referrals.) - [Recommendations and counselling] (Summarise advice given to the patient, including safety netting or education. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) [Patient education provided] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet points and include information about diagnosis, procedures, risks, rehabilitation, and care adherence.) - [Other actions or referrals] (Include lifestyle advice, specialist referrals, or allied health input. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) (Repeat the entire structure above for each orthopaedic issue and its management plan discussed during the consultation.) "Kind regards," (Write this entire note directed toward the patient in second person language. Use warm, friendly and clear language suitable for clinician-patient communication.)