Orthopaedic Surgery Consult

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Orthopaedic Surgery Consult

Date/Time:
Reason for referral: 

History of Present Illness: 
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems specific to the speciality]

Past Surgical History: 
(Hyphenated list)

Past Medical History:
(Hyphenated list)

Medications:
(Hyphenated list)
- [Medication name, dose, route, frequency if mentioned]
- [e.g., Metformin 500 mg oral BID]

Allergies:
(Hyphenated list)
(If no known allergies, state exactly “No known drug allergies (NKDA)”)

Social History:
(Hyphenated list)
- [Living situation] (if mentioned)
- [Occupation] (if mentioned)
- [iADLs, ADLs] (if mentioned)
- [Tobacco use status: pack-years, quit date if applicable] (if mentioned)
- [Alcohol use] (if mentioned)
- [Recreational drug use] (if mentioned)

Physical Examination:
(Hyphenated list)
- [Vital signs in one line if mentioned (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)]
- [Weight, height, BMI if mentioned]
- [Stated physical examination findings, one line per system. If a normal exam is mentioned, use standard phrasing (eg., Respiratory: Chest clear to auscultation bilaterally, no wheezes or crackles; Cardiac: Normal S1/S2, no murmurs, rubs or gallops; Abdomen: Soft, non-distended, non-tender.)]

Investigations:
(Hyphenated list)
- [Lab values if mentioned in one line using abbreviations]
- [Imaging if mentioned]

Assessment & Plan: 
(Use medical terminology if appropriate)
[One-sentence patient summary including age, sex, and surgical assessment.]

#) [Assessment as a numbered item] 
- [Hyphenated list with each corresponding plan item on a new line]

#) [Preoperative Risk Considerations]
- [Include if relevant: anticoagulation status, functional status, cardiac history, ASA class if assigned]
- [e.g., On warfarin for atrial fibrillation; will require bridging. History of MI 2019.]

#) [Consent Discussion if mentioned]
- [Document whether consent was obtained and what was discussed — risks, benefits, alternatives]