Ortho Consult

Consultation: [Town of consultation](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Place of consultation such as Rooms, Ward, Emergency Department, EC, Hand Clinic, or Theatre](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Patient: [Patient's full name](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) File number: [Patient's unique file identification number](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Referred by: [Referring physician's full name](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Cc: [Names or roles of individuals or departments to be carbon copied on the communication](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Co-morbidities: [All co-existing medical conditions or diseases](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Diagnosis: [Medical diagnosis or primary health concern](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) Date of injury: [Date of the injury or onset of symptoms](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Summary of healthcare encounter: [Summary of the consultation setting and primary purpose of the encounter](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Subjective: - [Patient's age, hand dominance, and occupation](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Patient's chief complaint including affected side, onset, duration, and specific characteristics of symptoms](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Details of the injury event including how it occurred, associated sounds, and immediate symptoms](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Pain severity, consistency, and any changes since the injury](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Circumstances of the injury, specifically if work-related and the type of activity involved](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Patient's current work status including sick leave and discussions about returning to work](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Name of the patient's general practitioner or primary care physician](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Current medications being taken by the patient including over-the-counter drugs or supplements](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Known allergies to medications, food, or environmental factors, and any history of adverse reactions to anaesthesia](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Objective: - [Findings from the physical examination detailing specific areas of pain and tenderness](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Assessment of muscle strength and pain during specific movements or resistance tests](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Results from diagnostic imaging indicating whether findings are normal or abnormal](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Information regarding ongoing or previous attendance at physiotherapy](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Assessment & Plan: 1. [Primary problem or diagnosis being addressed](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) - [Suspected nature of the injury based on mechanism and clinical presentation](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Recommended further investigations specifying the type of imaging and anatomical area to be assessed](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Potential future interventions such as surgical options and conditions under which they would be considered](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Management strategy if specific findings are identified on further imaging, including pain management](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Counselling provided to the patient regarding potential recovery time and work implications](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Explanation given to the patient regarding the nature of their injury, rationale for proposed investigations, and limitations of certain treatments based on tissue type](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Additional Notes: Clinical Examination: [Detailed observations from the physical examination including painful areas, muscle strength, and findings on resisted movements](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Diagnostic Imaging Findings: [Summary of results from initial diagnostic imaging stating whether findings were within normal limits](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Treatment Plan: - [Specific diagnostic procedures or imaging studies to be undertaken](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Next steps in patient management following imaging results including re-evaluation and consideration of surgical intervention](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Discussion regarding the patient's return to work including consideration of partial duties](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)