Imaging Review Note (Orthopedic Surgery)

Note Type: Imaging Review Note (Orthopedic Surgery)
Author/Service: [name, credentials, specialty]
Date/Time of Review: [date and time images were reviewed]
Review Context: [trigger for review]

Clinical Question

[Orthopedic question, working diagnosis or leading clinical concern, and explicit laterality/region] (Keep to 1–3 sentences. If indication is unclear from available documentation, note this and how the review proceeded.)

Imaging Reviewed

(For each study: modality + anatomy + laterality, date performed, source, and what was reviewed. Include comparison studies if used. Note limitations only if they affect interpretation. Always state laterality or flag inability to confirm.)

• [Modality] [anatomy/region] [laterality] — [date performed]; [source]; [images personally reviewed / radiology report reviewed / both]; [comparison studies if used]; [limitations if material]
• (Additional studies as applicable)

Relevant Clinical Context

[Pertinent symptoms, mechanism if trauma, relevant prior treatment, and key exam findings with date] (Include only if it materially affects interpretation or management. If no physical exam was performed, state: "No physical exam performed as part of asynchronous image review." Omit this section entirely if context is established elsewhere or not needed.)

Findings

[Key orthopedic imaging findings using terminology that informs management: alignment, displacement, stability, hardware status, cartilage/meniscus/ligament integrity, staging/classification] (Lead with highest-impact finding. Quantify in mm/degrees/percentage when possible. Use calibrated uncertainty language and name limitations when appropriate. For incidental non-orthopedic findings, briefly note acknowledgment and routing.)

Impression

• [Primary orthopedic diagnosis with severity/staging/classification if applicable]
• [Correlation linking imaging to symptoms and/or exam findings]
• [Key management-changing negatives or uncertainties] (Include only if relevant)

Plan

(Problem-oriented format. For each problem, state assessment and plan including nonoperative vs operative management, additional diagnostics with rationale, and follow-up timing/purpose. Document any communication that occurred for urgent findings: who was contacted, method, date/time, content, and response.)

[Problem: region/laterality — diagnosis or leading differential]: [Assessment of diagnosis/status] — [Plan: management approach, additional diagnostics, follow-up, and communication if applicable]

(Additional problems as applicable)

Electronic Signature: [name, credentials]
Date/Time Signed: [date/time]

(If addendum: clearly label with date/time and summarize what changed without overwriting original content.)