Best Orthopaedic Note

Thank you for referring [patient first name] to me. **Provisional or final diagnosis:** [brief working orthopaedic diagnosis or problem list] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Only include orthopaedic diagnoses. List diagnoses if more than one. Do not include presenting complaint, demographics, or medical history. Write in short paragraphs using full sentences, and do not use bullet points.) **Plan:** [treatment and/or further investigation plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Keep brief and focused. Only include specific plans as dictated. Write in full sentences and paragraphs. Do not use bullet points.) **History:** [relevant history relating to the current condition or complaint] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include all reported symptoms and the patient’s version of the history in detail. Mention who attended the appointment with the patient if stated. Include any other medical conditions or problems even if unrelated, as a separate paragraph. Mention any relevant previous orthopaedic surgery. Write in full sentences and paragraphs. Do not use bullet points.) [current medications and their context] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include all prescribed and over-the-counter medications, including pain medication and medication for medical conditions. Mention any benefits or side effects if stated. Write in full sentences and paragraphs. Do not use bullet points.) [other non-medication treatments or interventions used] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include any non-pharmacological treatments or interventions such as physiotherapy, bracing, or injections. Write in full sentences and paragraphs. Do not use bullet points.) [patient's expectations or goals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include any stated expectations or goals the patient may have expressed regarding outcomes, treatment preferences or recovery. Write in full sentences and paragraphs. Do not use bullet points.) **Clinical:** [physical examination findings and any procedures performed during consultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include details of clinical examination, special tests, any procedures such as injections performed in the room, and any further information provided during the consultation. Write in full sentences and paragraphs. Do not use bullet points.) **Radiology:** [radiology results and interpretations] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include findings from X-rays, MRIs or other imaging modalities, along with interpretations. Mention the radiology provider if known. Write in full sentences and paragraphs. Do not use bullet points.) **Discussion:** [summary of discussion with the patient about diagnosis and treatment options] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include detailed summary of what was discussed, including diagnosis, treatment options, rationale, and timelines. Do not include any discussion of cost or fees. Write in full sentences and paragraphs. Do not use bullet points.) Total consultation length: [insert the duration of the consult in minutes] from [start time of consult in HH:MM format] to [end time of consult in HH:MM format] (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 section blank. Use as many lines, paragraphs, depending on the format, as needed to capture all the relevant information from the transcript. Do not use any bullet points of any type. Refer to patient by their first name throughout the letter.)