Consultation Note (Sports Medicine/Orthopedics Referral)

Date/Time of Service: [Date and time of encounter]

Author: [Name, degree(s), credentials, role]

Location: [clinic / training room / inpatient / other]

Referral Source: [Requesting clinician/service and contact information]

Participants Present: [patient alone / family member(s) / PT / ATC / coach / other]

Reason for Consult

[Consult question from referring team]

[Clarification details, if applicable] (Include only if the original question required clarification; document original request, what was clarified, and any remaining ambiguity.)

Executive Summary

[Case identifier: orthopedic condition/procedure, phase of recovery, key behavioral concern]

Behavioral impression: [Headline-level impression, e.g., fear-avoidance/kinesiophobia, pain catastrophizing, adherence ambivalence, low psychological readiness for graded exposure]

• [Recommendation 1: action, rationale, responsible party, timeframe]
• [Recommendation 2: action, rationale, responsible party, timeframe]
• [Recommendation 3: action, rationale, responsible party, timeframe]
• [Additional recommendations as needed] (Include only if clinically indicated; aim for 3–5 total.)

Information Sources and Scope

• Sources reviewed: [patient interview / collateral contacts / PT notes / ATC notes / orthopedic notes / operative notes / imaging / prior behavioral health records]
• Scope: [one-time evaluation / ongoing co-management]; [areas explicitly outside scope, e.g., physical clearance for return-to-play]
• Limitations: [language barriers / time constraints / incomplete records / acute distress / none] (Use "Not assessed" for areas not evaluated.)

Consent and Information Sharing

[Consent status for evaluation and collateral contacts]. Findings and recommendations will be shared with the referring medical team as part of integrated care. [Information withheld at patient request, if any, and impact on recommendations] (Keep brief and encounter-specific.)

Chief Concern and Injury Summary

Patient statement: "[Brief quote capturing behavioral target]" (Include only if clinically illustrative.)

• Orthopedic diagnosis: [Condition and laterality]
• Surgery/procedure: [Procedure and date / none]
• Rehab phase: [immediate post-op / subacute / strengthening / return-to-sport preparation / maintenance]
• Restrictions: [Weight-bearing, ROM, activity limitations]
• Return-to-sport status: [not cleared / phased clearance / full clearance with restrictions / full clearance]
• Current treatments: [PT frequency, home exercise program, bracing, medications, injections]

Behavioral History

[Narrative summary of behavioral factors affecting rehabilitation: recovery timeline and setbacks, adherence behaviors, fear of re-injury patterns with triggers and avoidance, pain experience and coping, functional impact, previous facilitators of adherence/confidence] (Use "Not assessed" where applicable.)

• Key barriers: [Top behavioral barriers]
• Key facilitators: [Supports and effective strategies]

Relevant Background

(Include only history directly relevant to the consult question.)

• [Prior injuries and rehab experiences]
• [Medical/surgical history affecting recovery or exercise tolerance]
• [Current medications, especially analgesics or psychotropics]
• [Behavioral health history: prior diagnoses, treatments, hospitalizations]
• [Substance use, if relevant to pain management or mood]
• [Sleep patterns]

Sport and Psychosocial Context

(Include only content that informs formulation and recommendations.)

• [Athletic identity and meaning of sport]
• [Team/organizational pressures: scholarship, contract, selection timeline, role loss]
• [Support system: family, teammates, PT/ATC alliance]
• [Current stressors: academics, work, finances]
• [Communication patterns with treatment team]
• [Motivation and readiness for change]
• [Strengths and protective factors]

Objective Findings

• Behavioral observations: [Appearance, engagement, psychomotor activity, affect, pain behaviors, guarding]
• Mental status: [Appearance/behavior, speech, mood/affect, thought process/content, cognition, insight/judgment] (Include only when behavioral assessment is substantive.)
• Standardized measures: [Instrument name, score, interpretation, implications for recommendations] (Omit section if none administered.)

Risk Assessment

[Suicidal ideation assessment and findings] (At minimum, document whether SI was assessed. If concerns present, include ideation, intent, plan, means access, past attempts, protective factors, safety plan, and disposition. Do not autopopulate negatives without explicit assessment; use "Not assessed" if not evaluated.)

Assessment

Diagnostic impression: [Orthopedic diagnosis] + [Behavioral diagnosis or problem descriptor: fear-avoidance/kinesiophobia, adjustment reaction to injury, anxiety, depression] (Distinguish expected adjustment from clinically impairing conditions.)

Behavioral formulation:

• Predisposing: [Prior injury history, baseline anxiety, perfectionism]
• Precipitating: [Injury event, re-injury scare, pain flare]
• Perpetuating: [Avoidance, catastrophizing, sleep disruption, unclear expectations]
• Protective: [PT alliance, clear goals, prior coping success]

Mechanism: [How identified factors interact to affect adherence and readiness]

Recommendations

• [Communication alignment: unified messaging about hurt vs. harm, expected soreness; responsible party; timeframe]
• [Adherence supports: scheduling, goal-setting, accountability; responsible party; timeframe]
• [Graded exposure plan: feared movements and stepwise progression with PT; responsible party; timeframe]
• [Pain coping skills: pacing, relaxation, cognitive reframing, sleep optimization; responsible party; timeframe]
• [Readiness monitoring: instrument/criteria and review cadence; responsible party; timeframe]
• [Escalation/referral pathway: sport psychology, psychiatry, pain program; trigger criteria; responsible party]

Patient-facing plan: [Skills taught/practiced, homework assigned, patient preferences and agreed actions]

Follow-up: [Timing and modality for follow-up or PRN re-consultation; focus areas for next contact]

Communication to Referring Clinician

[Method: note routed / secure message / phone call / in-person], [recipient name and role], [date/time]. [Immediate notification and response if urgent safety concerns identified]