Orthopedic Surgeon

10-15 minutes

SOAP Dual

The Dual SOAP note template from s10.ai is expertly crafted for orthopedic surgeons handling multiple patients during a single consultation. This template empowers clinicians to meticulously document subjective and objective findings, assessments, and individualized treatment plans for each patient, ensuring accuracy and clarity. Perfect for managing sports injuries or musculoskeletal issues, this template facilitates efficient documentation of intricate cases. The Dual SOAP format is especially beneficial for orthopedic practices where numerous patients are attended to in rapid succession, optimizing the documentation workflow while preserving detailed and comprehensive patient records.

1,902 uses

4.2/5.0

James Thompson

Template Structure

Organized sections for comprehensive clinical documentation

(This is a session involving one clinician and multiple patients. Ensure each patient's input is clearly distinguished to accurately reflect their contributions during the session.) (Utilize dashes for bullet points throughout both notes.)

Patient 1: [Name of First Patient]

Subjective: (include only details pertinent to the first patient, Patient 1)

- [describe current issues, reasons for visit, discussion topics, history of presenting complaints, etc.] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

- [describe review of systems, e.g., other associated symptoms including both positive and negative symptoms] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

- [describe past medical history, previous surgeries] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

- [mention medications and herbal supplements] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

- [describe social history] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

- [mention allergies] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

Objective: (include only details pertinent to the first patient, Patient 1)

- [vital signs] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

- [physical examination findings] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

- [laboratory and imaging results] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

Assessment: (include only details pertinent to the first patient, Patient 1)

- [diagnosis or clinical impression] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

Plan: (include only details pertinent to the first patient, Patient 1)

- [treatment plan, medications prescribed, follow-up instructions] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

Patient 2: [Name of Second Patient]

Subjective: (include only details pertinent to the second patient, Patient 2)

- [describe past medical history, previous surgeries] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

- [mention medications and herbal supplements] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

- [describe social history] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

- [mention allergies] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

Objective: (include only details pertinent to the second patient, Patient 2)

- [vital signs] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

- [physical examination findings] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

- [laboratory and imaging results] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

Assessment: (include only details pertinent to the second patient, Patient 2)

- [diagnosis or clinical impression] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

Plan: (include only details pertinent to the second patient, Patient 2)

- [treatment plan, medications prescribed, follow-up instructions] (include only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)

[Disclosure:

- Patient informed that the medical note may be supplemented with the use of an ambient listening aid with audio recording. (include this section only if discussed or patient explicitly informed)]

Sample Clinical Note

Example of completed documentation using this template

Patient 1: John Smith  
Subjective:  
- John reports ongoing knee pain after a sports injury two weeks ago, with swelling and difficulty bending the knee.  
- Denies experiencing fever or redness around the knee.  
- No notable past medical history or surgeries.  
- Currently using ibuprofen as needed for pain relief.  
- Social history includes regular recreational soccer participation.  
- No known allergies.  
Objective:  
- Vital signs: BP 120/80 mmHg, HR 72 bpm, Temp 36.8°C.  
- Physical examination shows tenderness on the medial side of the knee with restricted range of motion.  
- X-ray reveals no fractures, MRI is pending.  
Assessment:  
- Suspected medial meniscus tear.  
Plan:  
- Advise MRI to confirm the diagnosis.  
- Prescribe physical therapy and continue ibuprofen for pain control.  
- Follow-up in two weeks.  
Patient 2: Emily Johnson  
Subjective:  
- Emily reports lower back pain radiating to the left leg, worsening over the past month.  
- Describes numbness in the left foot.  
- History of lumbar disc herniation two years ago.  
- Currently taking gabapentin for nerve pain.  
- Works a desk job, leading a sedentary lifestyle.  
- Allergic to penicillin.  
Objective:  
- Vital signs: BP 118/76 mmHg, HR 68 bpm, Temp 37.0°C.  
- Physical examination reveals a positive straight leg raise test on the left side.  
- MRI shows L4-L5 disc herniation.  
Assessment:  
- Aggravation of lumbar disc herniation.  
Plan:  
- Refer to physiotherapy for core strengthening exercises.  
- Consider epidural steroid injection if symptoms do not improve.  
- Follow-up in four weeks.  
Disclosure:  
- Patient informed that the medical note may be supplemented with the use of an ambient listening aid with audio recording.

Clinical Benefits

Key advantages of using this template in clinical practice

This comprehensive clinical template is designed to streamline documentation for multiple patient visits with a single clinician, ensuring clarity and precision in capturing each patient's unique medical narrative. By differentiating between patients, this template facilitates accurate reflection of individual discussions, symptoms, and treatment plans, enhancing the quality of patient care. Clinicians can efficiently document subjective and objective findings, assessments, and plans for each patient, while maintaining a structured format that supports thorough review and follow-up. This template is ideal for busy healthcare settings, promoting efficient workflow and improved patient outcomes. Explore and implement this template to optimize your clinical documentation process today.

Frequently Asked Questions

Common questions about this template and its usage

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