Orthopaedic Surgeon Template

Ortho - New Patient Note

A professional Orthopaedic Surgeon template for healthcare professionals.

About this template

Need a clear and concise record of your orthopaedic consultation? This Ortho - New Patient Note template is designed for orthopaedic surgeons to efficiently document patient visits. It helps you capture essential details like the reason for the visit, medical history, physical exam findings, and treatment plans. This template ensures comprehensive documentation, making it easier to track patient progress and manage care. Streamline your note-taking process and improve accuracy with this valuable tool.

Preview template

**Reason For Visit:** Right shoulder pain and limited range of motion. **Date of onset or injury or list the duration of symptoms. List the duration of symptoms if no specific date is available. Otherwise estimate the duration using a term like "acute" or "chronic."** Symptoms started approximately 6 weeks ago. **Subjective:** Mr. John Smith, a 55-year-old right-hand dominant male, presents with right shoulder pain. He works as a carpenter and enjoys playing golf on weekends. He denies any other associated injuries. Mr. Smith reports the onset of right shoulder pain approximately six weeks ago, following a weekend of heavy lifting. The pain is described as a dull ache, exacerbated by overhead activities and at night. He denies any previous injuries to the shoulder. He has tried over-the-counter pain relievers with minimal relief. He reports that the pain is affecting his ability to work and play golf. Mr. Smith is a carpenter and plays golf on weekends. He denies any other physical activities. Mr. Smith denies smoking, drinks alcohol occasionally, and denies any illicit drug use. **Past Medical History:** Mr. Smith has a history of hypertension, well-controlled with medication. He had a left knee arthroscopy 5 years ago. He denies any other musculoskeletal disorders. Mr. Smith is currently taking lisinopril for hypertension. He denies any other medications. Mr. Smith denies any known drug allergies. **Physical Exam:** No obvious deformity or swelling was noted. There was no evidence of skin breakdown or infection. Active range of motion: Flexion 120 degrees, abduction 90 degrees, external rotation 30 degrees, internal rotation to the level of T12. Passive range of motion was similar. Tenderness to palpation over the supraspinatus tendon and the anterior aspect of the glenohumeral joint. No instability was noted. Strength testing revealed 4/5 strength in abduction and external rotation. Sensation was intact to light touch in the deltoid region. Spurling's test was negative. **Investigations/Other Studies Reviewed:** Right shoulder X-rays were reviewed, showing mild acromioclavicular joint arthrosis. **Assessment & Plan:** 1. Right shoulder impingement syndrome. ICD-10 Code: M75.10, Unspecified rotator cuff syndrome. ICD-10 Code: M75.12, Bicipital tendinitis. Patient is progressing as expected. Differential diagnosis includes rotator cuff tear, glenohumeral arthritis. Plan for MRI of the right shoulder. Referral to physiotherapy for conservative management. Patient was informed of both operative and nonoperative treatment options. Nonoperative treatment includes physiotherapy, activity modification, and NSAIDs. Operative treatment includes arthroscopic subacromial decompression and/or rotator cuff repair. Patient is interested in trying conservative management first. **Follow-up:** Follow-up in 4 weeks in person to assess response to physiotherapy and review MRI results. X-rays to be obtained at next visit. **CPT Codes:** 99203: Office or other outpatient visit for the evaluation and management of a new patient. 73030: Radiologic examination, shoulder; 2 views.

**Reason For Visit:** [Reason(s) for consultation, including specific musculoskeletal concerns or symptoms such as joint pain, stiffness, swelling, injuries, fractures, deformities, numbness, pain, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Date of onset or injury or list the duration of symptoms. List the duration of symptoms if no specific date is available. Otherwise estimate the duration using a term like "acute" or "chronic." (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Subjective: [Use full sentences to provide a one-line description of the patient's age, gender, hand dominance, occupation, recreational activities, and any other associated injuries they had (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Use full sentences to provide detailed history of the presenting complaint(s), including onset, duration, severity, aggravating/alleviating factors, associated symptoms such as limitation of movement, previous injuries, trauma, any previous treatments such as physiotherapy or medications or surgeries and responses, and mention any ways this is affecting the patient's level of activity. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Use full sentences to provide social history focusing on occupation, hand dominance, sports, physical activities, and lifestyle factors that may influence musculoskeletal health (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Use full sentences to provide socioeconomic history highlighting smoking, alcohol consumption, drug use, and any behavioral or socioeconomic problems, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Past Medical History: [Medical and surgical history focusing on any heart or lung problems, endocrine problems, kidney or liver problems, blood clots or bleeding disorders, previous orthopedic surgeries, musculoskeletal disorders, hospitalizations, outcomes, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Current medications, including any pain management medications, anti-inflammatories, supplements, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Allergies, including allergies to medications, or other materials relevant to orthopedic procedures, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Physical Exam: [A brief description of musculoskeletal physical examination findings related to the wound including if there is healing as expected, delayed healing, or local evidence of infection such as induration, erythema, drainage or wound breakdown (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [A brief description of musculoskeletal physical examination findings related to active range of motion. If this is for the elbow or forearm it should include flexion and extension as well as supination and pronation. Use specific numerical measurements if available, use subjective descriptors such as "reduced" or "good" or "excellent", or relative indicators such as "reaches face" or "reaches head" or "makes a full fist" if no numerical measurements are available. Mention passive range of motion if this is specifically mentioned (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [A brief description of musculoskeletal physical examination findings related to joint stability or if there are specific areas of tenderness (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [A brief description of musculoskeletal physical examination findings related to nerve function including strength testing, sensation, and any provocative nerve exams such as Spurling's sign, Tinel sign at the elbow and wrist, elbow or wrist flexion tests, carpal tunnel compression test (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] (Do not mention imaging studies in the Physical Exam section) Investigations/Other Studies Reviewed: [Investigations with results, including imaging and laboratory tests, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Assessment & Plan: [1. List the most important orthopedic issue or condition. Delineate a specific diagnosis. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Include a best estimate of the ICD 10 code, including the description of that code. Also include a second-best estimate of the ICD 10 code, including the description of that code. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Assessment of progress down recovery pathway, including if there are unexpected events or complications, if the patient is progressing as expected (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Differential diagnosis, considering other potential musculoskeletal or systemic conditions that may present with similar symptoms (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Investigations planned, specifying any additional imaging, laboratory tests, or assessments needed for a definitive diagnosis or surgical planning (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Relevant referrals, e.g., to rheumatology, physiotherapy, pain management, etc., if needed (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [If there was a discussion of multiple treatment pathways such as operative and nonoperative treatments, include a small description of each possible pathway (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Surgical treatment planned, detailing the type of surgery, expected outcomes, and potential risks, including if the patient would like to proceed with surgical or nonsurgical intervention (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [If any details about the surgery are mentioned such as location, duration, or anesthesia plan, mention them in a single sentence here. Do not mention any equipment lists (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Post-operative care plan, covering expected hospital stay if applicable, activity restrictions, wound care, rehabilitation and therapy, pain management (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Instructions how to monitor for signs of complications to watch for and how to seek care (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Patient education on the diagnosed condition, surgical procedures, potential complications, and the importance of rehabilitation and adherence to post-operative care (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Any specific patient or family concerns addressed during the consultation (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [2. Additional Orthopedic Issues or Conditions] [Follow the same structure as above for each additional issue or condition identified (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Follow-up: [If the patient is going to come back to clinic, list the follow-up plan for next visit including if it is in person or telemedicine and location, the timing of the next visit, and what the purpose of the next visit will be such as repeat XRs or wound check or range of motion check, and list any other studies that should be available for review before the next visit such as MRI scans, CT scans, or electromyogram or nerve conduction studies, including if XRs are to be obtained at their next clinic visit (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] CPT Codes: [List the 10 most likely CPT codes for this visit with the reason and an explanation (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] (For each section, 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, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)

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