Orthopaedic Surgeon Template

Secondary survey

A professional Orthopaedic Surgeon template for healthcare professionals.

About this template

Need a comprehensive record of a patient's injuries and care following a traumatic event? This Secondary Survey template is designed for orthopaedic surgeons and other medical professionals to meticulously document a patient's condition after the initial assessment. It covers everything from the mechanism of injury and detailed examination findings to the ongoing care plan. With Heidi, this template can be quickly populated from your patient's visit transcript, saving you time and ensuring thorough documentation. This is a great example of a medical documentation template.

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Completed by: Dr. Eleanor Vance Patient History Mechanism Patient involved in a high-speed motorcycle accident. Impact occurred on the left side of the body after the motorcycle collided with a stationary vehicle. Patient was thrown from the motorcycle and landed on the road surface. Injuries Left open femur fracture, left tibial plateau fracture, multiple rib fractures (left side), closed head injury with suspected concussion, and abrasions to the left upper extremity. Past Medical History Patient has a history of hypertension, managed with medication. No prior surgeries. Patient’s normal medications Lisinopril 20mg daily. Social History Lives with another Lives with his wife. Known drug allergies - Penicillin: Rash Tetanus Status Up To Date Open fracture YES Antibiotics administered Cefazolin 2g IV administered at 14:00. Photo taken with consent YES Pelvic ring injury? YES Checklist completed YES (**please mark as appropriate**) Secondary Survey Detail Head - Minor scalp laceration, no obvious skull fractures. GCS 14 (E4, V4, M6). Pupils equal and reactive to light. Neck - No step-offs or deformities. Tenderness to palpation in the cervical region. Full range of motion. Chest - Multiple rib fractures noted on palpation and inspection. Bilateral equal air entry. Abdo - Soft, non-tender abdomen. No guarding or rigidity. Pelvis - Pelvis stable to palpation. No crepitus. Back - No obvious deformities or bruising. Limbs - Left open femur fracture with significant deformity. Left tibial plateau fracture. Abrasions to the left upper extremity. Neurovascularly intact in all limbs. Neurology - GCS 14. Cranial nerves II-XII intact. Motor strength 5/5 in all limbs except left lower extremity (unable to assess due to fracture). Sensory intact to light touch and pinprick in all limbs. Reflexes 2+ and symmetrical. Muscle Group (Power 0-5) Right Left Shoulder abduction 5 5 Shoulder adduction 5 5 Elbow flexion 5 5 Elbow extension 5 5 Wrist flexion 5 5 Wrist extension 5 5 Hip flexion 5 Unable to assess Hip extension 5 Unable to assess Knee flexion 5 Unable to assess Knee extension 5 Unable to assess Ankle flexion 5 Unable to assess Ankle dorsiflexion 5 Unable to assess Reflexes Right Left Biceps 2+ 2+ Triceps 2+ 2+ Supinator 2+ 2+ Knee 2+ 2+ Ankle 2+ 2+ Plantar Normal Normal Perianal/ rectal exam Normal Abnormal Comment Perianal sensation Normal Buttock clench Normal Rectal exam Normal On-Going Care VTE Prophylaxis Prescribed Yes Analgesia Adequate Yes Trauma and Orthopaedic Plan 1 - Stabilize fractures. 2 - Perform open reduction and internal fixation (ORIF) of the femur fracture. 3 - Evaluate and manage tibial plateau fracture. 4 - Monitor for compartment syndrome. 5 - Initiate early mobilisation. Speciality plan Team General Surgery Plan - Monitor for intra-abdominal injuries. - Continue serial abdominal exams. - Consult for further management of rib fractures. Major Trauma Spinal Clearance Checklist for Current Admission Completed by: Dr. Eleanor Vance Spine cleared Yes If yes, Complete Below Precautions ‘X’ Appropriate Details FULL Patient to remain in full spinal precautions until further imaging is completed. Copy Neurosurgical advice and CODE (if applicable) below: Neurosurgery consulted. Advised close neurological monitoring and repeat CT head in 24 hours. No immediate intervention required. Code: 99255

Completed by: [Name of person completing the form] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Patient History Mechanism [Detailed description of the mechanism of injury and history of presenting complaint, including forces involved, circumstances, and any relevant events leading to the injury] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Injuries [Comprehensive list and description of all identified injuries, including location, type, and severity] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Past Medical History [Detailed account of the patient's past medical conditions, significant illnesses, previous surgeries, and any chronic diseases] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Patient’s normal medications [List of all medications the patient regularly takes, including dosage, frequency, and route] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Social History Lives Alone [Indication if the patient lives alone] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Lives with another [Indication if the patient lives with another person, specifying who they live with] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Has Care Package [Indication if the patient has a care package, including details of the care provided] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Independent [Indication if the patient is independent in daily activities] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Walks with aids [Indication if the patient walks with aids, specifying the type of aid used] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Bed / Chair bound [Indication if the patient is bed or chair bound] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Known drug allergies - [List of all known drug allergies, including the reaction experienced] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Tetanus Status Up To Date [Indication if tetanus status is up to date] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Not required [Indication if tetanus is not required] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Given in ED [Indication if tetanus vaccine was given in the Emergency Department] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Open fracture YES [Indication if an open fracture is present] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Antibiotics administered [Confirmation of antibiotic administration for open fracture, including type and time] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Photo taken with consent [Confirmation that a photo of the open fracture was taken with consent] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Pelvic ring injury? YES [Indication if a pelvic ring injury is present] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Checklist completed [Confirmation that the pelvic ring injury checklist has been completed] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (**please mark as appropriate**) Secondary Survey Detail Head - [Detailed findings from the head examination during the secondary survey, including any signs of trauma, lacerations, deformities, or neurological signs] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Neck - [Detailed findings from the neck examination during the secondary survey, including palpation for tenderness, crepitus, swelling, and range of motion assessment] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Chest - [Detailed findings from the chest examination during the secondary survey, including inspection, palpation, percussion, and auscultation for signs of injury or compromise] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Abdo - [Detailed findings from the abdominal examination during the secondary survey, including inspection, palpation for tenderness or rigidity, and auscultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Pelvis - [Detailed findings from the pelvic examination during the secondary survey, including stability assessment, tenderness, and signs of injury] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Back - [Detailed findings from the back examination during the secondary survey, including inspection for deformities or bruising, and palpation for tenderness] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Limbs - [Detailed findings from the examination of all limbs during the secondary survey, including assessment for deformities, swelling, tenderness, range of motion, and neurovascular status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Neurology - [Detailed neurological assessment findings during the secondary survey, including conscious level, cranial nerves, motor and sensory function, and reflexes] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Muscle Group (Power 0-5) Right Left Shoulder abduction [Right shoulder abduction power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left shoulder abduction power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Shoulder adduction [Right shoulder adduction power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left shoulder adduction power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Elbow flexion [Right elbow flexion power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left elbow flexion power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Elbow extension [Right elbow extension power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left elbow extension power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Wrist flexion [Right wrist flexion power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left wrist flexion power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Wrist extension [Right wrist extension power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left wrist extension power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Hip flexion [Right hip flexion power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left hip flexion power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Hip extension [Right hip extension power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left hip extension power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Knee flexion [Right knee flexion power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left knee flexion power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Knee extension [Right knee extension power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left knee extension power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Ankle flexion [Right ankle flexion power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left ankle flexion power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Ankle dorsiflexion [Right ankle dorsiflexion power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left ankle dorsiflexion power (0-5)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Reflexes Right Left Biceps [Right biceps reflex status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left biceps reflex status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Triceps [Right triceps reflex status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left triceps reflex status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Supinator [Right supinator reflex status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left supinator reflex status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Knee [Right knee reflex status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left knee reflex status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Ankle [Right ankle reflex status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left ankle reflex status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Plantar [Right plantar reflex status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Left plantar reflex status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Perianal/ rectal exam Normal Abnormal Comment Perianal sensation [Indication if perianal sensation is normal or abnormal] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Detailed comment on perianal sensation if abnormal] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Buttock clench [Indication if buttock clench is normal or abnormal] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Detailed comment on buttock clench if abnormal] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Rectal exam [Indication if rectal exam findings are normal or abnormal] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Detailed comment on rectal exam findings if abnormal, including sphincter tone, presence of blood, or masses] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) On-Going Care VTE Prophylaxis Prescribed Yes [Indication if VTE prophylaxis was prescribed] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) No [Indication if VTE prophylaxis was not prescribed] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Not Applicable [Indication if VTE prophylaxis is not applicable] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Analgesia Adequate Yes [Indication if current analgesia is adequate] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) No [Indication if current analgesia is not adequate] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Not Applicable [Indication if analgesia adequacy is not applicable] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Trauma and Orthopaedic Plan 1 - [First point of the trauma and orthopaedic plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) 2 - [Second point of the trauma and orthopaedic plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) 3 - [Third point of the trauma and orthopaedic plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) 4 - [Fourth point of the trauma and orthopaedic plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) 5 - [Fifth point of the trauma and orthopaedic plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Speciality plan Team [Name of the speciality team involved] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Plan - [First point of the speciality team's plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Second point of the speciality team's plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Third point of the speciality team's plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Fourth point of the speciality team's plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Fifth point of the speciality team's plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Sixth point of the speciality team's plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Major Trauma Spinal Clearance Checklist for Current Admission Completed by: [Name of person completing the spinal clearance checklist] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Spine cleared Yes [Indication if the spine has been cleared] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) No [Indication if the spine has not been cleared] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) If yes, Complete Below Precautions ‘X’ Appropriate Details FULL [Indication if full spinal precautions are appropriate] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Details regarding full spinal precautions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Limited/Special Instructions [Indication if limited or special spinal instructions are appropriate] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Details regarding limited or special spinal instructions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Update/Changes [Indication if there are updates or changes to spinal precautions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Details regarding updates or changes to spinal precautions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) None [Indication if no spinal precautions are required] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Copy Neurosurgical advice and CODE (if applicable) below: [Detailed summary of neurosurgical advice and any associated codes if applicable] (Only include if explicitly mentioned in transcript or context, 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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Specialty

Orthopaedic Surgeon

Used

3 times

Type

Note

Last edited

10/7/2025

Created by

Rishabh Jain

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