Ortho - Follow Up / Post-Op Note

**Reason For Visit:** - [primary surgical procedure or clinical condition being followed up] (Only include if explicitly mentioned in transcript or context, else omit section entirely. State clearly whether this is a surgical follow-up or a non-surgical condition.) - [onset date or symptom duration] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Format as: "Date YYYY/MM/DD: [event or symptom start]". If no date, describe approximate duration such as “2 weeks ago”, “chronic”, or “acute”.) **Subjective:** (Use full sentences. Use a bulleted list. Do not use the word "reports".) - [demographics and functional background] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include age, gender, occupation, hand dominance, recreational activities, and relevant associated injuries.) - [history of presenting complaint] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include onset, duration, severity, aggravating/alleviating factors, associated symptoms, prior injuries or trauma, and previous treatments and responses.) - [work status] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Describe whether patient has returned to work, and if duties are modified or unchanged.) - [occupational therapy status] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include whether therapy has started, frequency, or reasons for not starting.) - [home exercise program] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include exercises performed, frequency, and adherence.) **Physical Exam:** (Use bullet points. Do not include imaging findings.) - [wound assessment] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include status of healing and any signs of infection such as erythema, induration, drainage, or breakdown.) - [range of motion] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include active ROM with specific measurements or descriptors. Include passive ROM only if specifically mentioned.) - [joint stability or tenderness] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include findings related to joint laxity or specific tenderness.) - [nerve function] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include strength, sensation, and results of special tests such as Tinel’s, Phalen’s, Spurling’s, or compression tests.) **Imaging/Other Studies Reviewed:** - [imaging and/or lab results] (Only include if explicitly mentioned in transcript or context, else omit section entirely. State that images were independently reviewed and interpreted.) **Assessment & Plan:** (Use full sentences. Use bullet points.) [1. Primary orthopaedic issue or condition] - [specific diagnosis] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [progress assessment] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include whether patient is progressing as expected or if complications are present.) - [referrals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include referrals to physiotherapy, rheumatology, pain management, etc.) - [planned investigations] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include any upcoming imaging, labs, or diagnostic studies.) - [treatment options discussed] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Summarise operative vs. non-operative pathways.) - [surgical details] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include location, duration, anesthesia plan. Do not include equipment lists, CPT or ICD codes.) - [post-operative care plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include expected hospital stay, activity restrictions, wound care, rehabilitation plan, and pain management.) - [complication monitoring instructions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include what complications to watch for and how to seek care.) "Additional Orthopaedic Issues or Conditions:" - [additional diagnosis and plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Follow the same structure as the primary issue.) "Additional Notes:" - [additional notes discussed with patient or family] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences. Include patient education, instructions, or concerns addressed.) **Follow-up:** - [timing and location of follow-up visit] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include whether visit is in-person or via telemedicine and clinic location.) - [purpose of follow-up visit] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include planned assessments such as wound check, ROM check, or imaging review.) - [special rooming or preparation instructions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include instructions such as use of cast room, need for translator, or accessibility accommodations.) (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 include 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.)