Orthopedic consult template

Orthopedic Consultation Note

Chief Complaint / Laterality
- Primary musculoskeletal complaint with side and joint/region.

History of Present Illness
- Onset (traumatic vs atraumatic), mechanism of injury if any, date of injury, and course since onset.
- Pain location, character, severity (0–10), radiation, mechanical symptoms (locking, catching, instability), swelling, and weakness.
- Aggravating/relieving factors, prior treatments (RICE, bracing, PT, injections, medications), and functional limitations (work, sport, ADLs).
- Red flags: fever, night pain, unexplained weight loss, neurologic deficit, open injury, or inability to bear weight.

Relevant History
- Prior injuries/surgeries to the same region, bone health, inflammatory disease, diabetes, smoking, anticoagulation, and occupation/sport demands.

Exam
- Inspection, palpation, ROM (active/passive), strength, stability/special tests, neurovascular status, and gait as relevant.
- Comparison to contralateral side when appropriate.

Imaging / Data Reviewed
- X-ray, MRI, CT, ultrasound, or outside records reviewed today with key findings.

Assessment
- Orthopedic diagnosis with acuity and contributing factors.
- Brief discussion of differential if uncertain.

Plan
- Nonoperative measures (activity modification, bracing, PT, medications, injections) and/or surgical options discussed.
- Risks/benefits/alternatives if procedure or surgery planned; consent status if obtained.
- Work/sport restrictions, DME, follow-up, and imaging orders.