Orthopaedics Template

Orthopaedics Consultation Note

A professional Orthopaedics template for healthcare professionals.

About this template

Streamline your orthopaedic practice with Heidi's Orthopaedics Consultation Note template. This essential tool is perfect for orthopaedic surgeons, sports medicine physicians, and other musculoskeletal specialists needing comprehensive and structured documentation. Accurately capture crucial details like the patient's diagnosis, presenting complaints, age, and occupational impact on their condition. The template also ensures thorough recording of past medical history and detailed discussion outcomes, including treatment plans and patient preferences. With Heidi, this template intelligently populates key sections from your consultation, ensuring a clear, concise, and complete record for every patient interaction, saving valuable time and enhancing clinical accuracy.

Preview template

Orthopaedics Consultation Note **Diagnosis/ Presenting Complaint** 45-year-old male presenting with a 3-month history of progressive right knee pain, exacerbated by activity and stairs. He reports occasional locking and a feeling of instability. Initial onset was gradual with no specific injury, but pain has worsened significantly in the past month, impacting daily activities. **Outcome** Diagnosed with medial meniscus tear and early osteoarthritis of the right knee. Recommended initial conservative management including physiotherapy, anti-inflammatory medication, and a knee brace. Discussed surgical options (arthroscopy for meniscectomy/repair) if conservative measures fail. Patient is agreeable to starting conservative treatment. **Age** 45 **Occupation** Construction Site Manager. His role involves frequent standing, walking on uneven surfaces, and occasional lifting, which significantly aggravates his right knee pain. He reports difficulty climbing scaffolding and inspecting sites due to his symptoms. **Past Medical History** No significant past medical history. No previous knee injuries or surgeries. Denies any chronic conditions such as diabetes or rheumatoid arthritis. No known allergies. **Discussion/ Outcome** The consultation involved a thorough review of the patient's symptoms, physical examination findings (tenderness over medial joint line, positive McMurray's test), and review of recent MRI imaging confirming a medial meniscus tear and mild chondral changes. Treatment options discussed included conservative management (physiotherapy focusing on strengthening and range of motion, NSAIDs, knee brace for support) and surgical intervention (arthroscopic meniscectomy or repair). The risks and benefits of both approaches were explained in detail. Patient expressed a preference to exhaust non-surgical options first. He demonstrated good understanding of the plan and potential need for future surgical assessment if symptoms persist or worsen. Agreed to start physiotherapy next week and follow up in 6 weeks with progress.

**Diagnosis/ Presenting Complaint** [describe the patient's diagnosis and primary reason for the orthopaedic consultation, including any relevant symptoms, onset, and progression of the condition] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Outcome** [document the immediate outcome of the consultation, including any diagnoses made, decisions reached, or initial recommendations provided] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Age** [state the patient's current age] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Occupation** [describe the patient's current occupation and any relevant physical demands or impact on their orthopaedic condition] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Past Medical History** [detail the patient's relevant past medical history, including any chronic conditions, previous injuries, or surgeries pertinent to their orthopaedic health] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Discussion/ Outcome** [provide a detailed summary of the discussion during the consultation, including treatment options presented, patient understanding and preferences, and the agreed-upon management plan or future steps] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (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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