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Orthopedic Surgeon
10-15 minutes

Orthopedic Follow-Up Note

The Orthopaedic Progress Note template by s10.ai is a vital resource for orthopaedic surgeons, facilitating the documentation of follow-up visits and treatment plans for patients with musculoskeletal conditions. This template is meticulously crafted to record detailed subjective and objective findings, encompassing patient symptoms, physical examination outcomes, and pertinent investigations. It provides a structured outline for assessing and planning both surgical and non-surgical treatments, ensuring thorough patient care. Perfect for documenting post-operative progress, this template enhances the efficiency of the documentation process, enabling clinicians to effectively monitor patient recovery and strategize future interventions.

1,930 uses
4.2/5.0
D
Dr. Emily Chen
Template Structure

Organized sections for comprehensive clinical documentation

Progress Note
[date of input]
Subjective:
- [Reason(s) for consultation, including specific musculoskeletal concerns or symptoms such as joint pain, stiffness, swelling, injuries, fractures, deformities, etc. Typically, this is a follow-up visit for an orthopedic surgery or treatment (mention if available)]
- [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 (e.g., physiotherapy, medications, orthopedic surgeries) and responses, etc. (mention if available)]
- [If undergoing physiotherapy, whether progress is favorable or unfavorable]
- [How the symptoms have changed since the last visit and overall patient progress]
Objective:
- [Vitals (mention if available)]
- [Physical examination findings, focusing on musculoskeletal examination including inspection, palpation, range of motion, strength testing, joint stability, presence of deformity, swelling, or tenderness, etc. (mention if available)]
- [Appearance of the surgical wound (if available)]
- [Neurovascular examination findings, assessing nerve function and blood supply in the affected area, if relevant (mention if applicable and if available)]
- [Investigations with results, including imaging and laboratory tests, etc. (mention if available)]
Assessment & Plan:
[1. Orthopedic Issue or Condition]
- [Assessment, including the likely diagnosis and rationale based on subjective and objective findings (mention if available)]
- [Investigations planned, specifying any additional imaging, laboratory tests, or assessments needed for a definitive diagnosis or surgical planning (mention if available)]
- [Surgical treatment planned, detailing the type of surgery, the nature of the surgery, and any techniques mentioned (mention if applicable and available)]
- [Non-surgical treatment options, including physiotherapy, casting or bracing, medications, lifestyle modifications, etc., (mention only if applicable and available)]
- [Post-operative care plan, covering expected hospital stay, rehabilitation, physiotherapy, pain management, and follow-up appointments (mention only if applicable and available)]
- [Relevant referrals, e.g., to rheumatology, physiotherapy, pain management, etc., if needed (mention if applicable and available)]
[2. Additional Orthopedic Issues or Conditions]
- [Follow the same structure as above for each additional issue or condition identified (if applicable and if available)]
Additional Notes:
- [Patient education on the diagnosed condition, surgical procedures, potential complications, and the importance of rehabilitation and adherence to post-operative care (mention only if applicable and available)]
- [Instructions for pre-operative and post-operative care, including activity restrictions, wound care, signs of complications to watch for (mention only if applicable and if available)]
- [Any specific patient or family concerns addressed during the consultation (mention only if applicable and if available)]
- ["Informed consent was obtained after a discussion of the nature of the treatment proposed, the nature of the condition, the treatment alternatives, the expected postoperative course, and material risks which include but are not limited to pain, swelling, wound complications, periprosthetic joint infection, venous thromboembolism, stiffness, instability, wear and loosening, fracture, neurovascular injury, leg length discrepancy, malalignment, medical/anesthetic complications, and even death. The patient gave informed consent for the discussed procedure." (Insert this section if surgery was planned)]
Sample Clinical Note

Example of completed documentation using this template

Progress Note  
1 November 2024  
Subjective:  
- The patient, a 45-year-old male, returns for a follow-up visit after knee arthroscopy. He describes ongoing joint pain and stiffness, especially in the mornings, along with occasional swelling. These symptoms started about six months ago following a sports-related injury. He has been participating in physiotherapy, which he reports is going well, with some improvement in his range of motion.  
- Since the previous appointment, the patient mentions a gradual decrease in pain but still faces movement restrictions.  
Objective:  
- Vitals: Blood pressure 120/80 mmHg, Heart rate 72 bpm.  
- Physical examination shows mild swelling and tenderness around the knee joint. Range of motion is slightly limited, with some discomfort noted during flexion.  
- The surgical wound appears clean and is healing well, with no signs of infection.  
- Neurovascular examination is normal, with intact sensation and adequate blood supply to the affected area.  
- Recent MRI indicates mild effusion and no significant structural damage.  
Assessment & Plan:  
1. Post-Arthroscopy Knee Pain  
- Assessment: Likely post-operative inflammation and stiffness. The diagnosis is supported by subjective reports and objective findings.  
- Investigations planned: None at this time, as current imaging is sufficient.  
- Surgical treatment planned: Not applicable.  
- Non-surgical treatment options: Continue physiotherapy focusing on strengthening and flexibility exercises. Prescribe NSAIDs for pain management.  
- Post-operative care plan: Continue with current rehabilitation protocol. Schedule follow-up in four weeks to assess progress.  
- Relevant referrals: None needed at this time.  
Additional Notes:  
- Patient education provided on the importance of adherence to physiotherapy and gradual return to activity.  
- Instructions for post-operative care include avoiding high-impact activities and monitoring for signs of complications such as increased swelling or redness.  
- Informed consent was obtained after a discussion of the nature of the treatment proposed, the nature of the condition, the treatment alternatives, the expected postoperative course, and material risks which include but are not limited to pain, swelling, wound complications, periprosthetic joint infection, venous thromboembolism, stiffness, instability, wear and loosening, fracture, neurovascular injury, leg length discrepancy, malalignment, medical/anesthetic complications, and even death. The patient gave informed consent for the discussed procedure.
Clinical Benefits

Key advantages of using this template in clinical practice

  • The Progress Note template is an essential tool for clinicians managing orthopedic patients, providing a comprehensive framework to document patient encounters effectively. This template facilitates detailed recording of subjective and objective findings, including musculoskeletal symptoms, physical examination results, and neurovascular assessments. It supports clinicians in formulating precise assessments and treatment plans, whether surgical or non-surgical, and ensures thorough documentation of patient progress, treatment responses, and post-operative care. By adopting this template, healthcare professionals can enhance clinical accuracy, streamline patient management, and improve communication with multidisciplinary teams, ultimately leading to better patient outcomes. Explore this template to optimize your orthopedic documentation and patient care processes.
Frequently Asked Questions

Common questions about this template and its usage

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