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Focused MSK / joint exam visit template
Use this for rheumatology or MSK visits dominated by one or a few joints—monoarthritis, regional pain, aspiration/injection counseling—where a structured joint exam and clear next steps matter most.
Template content
Copy or download, then paste into Wavo under My Templates.
Focused Joint / MSK Exam Visit Chief Complaint / Laterality - Joint(s) or region of concern with side and duration. History - Onset (traumatic vs atraumatic), inflammatory features, swelling, locking, instability, fever, skin breaks, sexual history/STI risk if septic arthritis considered, prior crystal disease, and prior injections/surgery to the joint. - Current anticoagulation and infection risk factors. Exam - Inspection, palpation, effusion, warmth, ROM (active/passive), stability, adjacent joints, entheses as relevant. - Neurovascular status and comparison to contralateral side. - Gait or function as indicated. Diagnostics - Imaging, labs, and synovial fluid studies ordered or reviewed. - Aspiration/injection performed today: yes/no (detail in procedure note if separate). Assessment - Leading diagnosis (e.g., crystal arthritis, inflammatory monoarthritis, OA flare, soft-tissue process) and urgency (rule-out septic joint). Plan - Meds (NSAIDs, colchicine, steroids), aspiration/injection, antibiotics if indicated, imaging, crutches/brace, and follow-up. - Escalation criteria for ED/ortho if septic arthritis cannot be excluded.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Keeps laterality, joint-specific findings, and red flags explicit.
- Supports crystal disease, OA flares, and inflammatory monoarthritis workups.
- Documents aspiration/injection decision-making without replacing a full procedure note.
- Cross-links cleanly to orthopedic and inflammatory arthritis templates.
- 1Monoarthritis and oligoarthritis evaluations
- 2Focused joint rechecks and injection visits
- 3Crystal arthritis and regional MSK rheumatology visits
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Chief Complaint Acute right knee swelling and pain since yesterday morning; no trauma. History Prior gout in first MTP; recent diuretic start. Pain 8/10, cannot flex fully. Low-grade temp at home 100.1°F. No IVDU; no skin ulcer over knee. On allopurinol inconsistently. Not anticoagulated. Exam Right knee warm moderate effusion; ROM 10–90° limited by pain; no instability. No calf swelling. Left knee unremarkable. Afebrile in clinic now. Diagnostics Arthrocentesis: 35 mL cloudy fluid; cell count pending; Gram stain no organisms; intracellular needle-shaped negatively birefringent crystals on polarizing microscopy. Assessment Acute right knee gouty arthritis; septic arthritis less likely given crystals and Gram stain but cell count pending. Plan Colchicine load/taper per protocol; continue allopurinol (do not stop during flare). Ice, elevation, brief rest. Call if fever ≥100.8, escalating redness, or pending cell count concerning—will contact patient with results. Follow up 1–2 weeks or sooner PRN.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
Put this template to work on your next visit
Start free, paste the template, and see how Wavo documents in your structure.