Orthopedic Surgery Admission H&P

Date/Time of Encounter: [Date and time of encounter]
Date/Time of Note: [Date and time of note]
Patient: [Patient name], [MRN], [DOB]
Location: [ED / floor / ICU / transfer facility]
Author: [Author name and role]
Admission Type: [ED admit / transfer / direct admit / post-op admit]
Interpreter: [Language and modality] (Include only if interpreter was used; otherwise omit this line.)
Code Status: [Full code / DNR / DNI / other] (Include only if established; otherwise omit this line.)

Chief Complaint

[Chief complaint in patient's own words when illustrative, in quotation marks]

History of Present Illness

[Narrative HPI beginning with a 1–2 sentence opener identifying the patient, main orthopedic problem, laterality, and timing. Continue covering: date/time of onset; location and laterality; symptom trajectory; functional impact including weight-bearing ability and ADL limitations; and any prior care before arrival such as splinting, reduction, antibiotics, analgesia, or imaging. Document information sources and any reliability limitations.]

(For trauma admissions, integrate: mechanism and energy level; environment and contamination risk for open wounds; prehospital immobilization or interventions; associated injuries; neurovascular symptoms; wound status; tetanus status.)

(For infection admissions, integrate: primary concern; timeline relative to any prior surgery; systemic symptoms; local findings; prior cultures and organism history; prior antibiotic exposure with timing; relevant immunocompromise or risk factors.)

(For perioperative/optimization admissions, integrate: surgical indication and planned procedure; pre-op medical readiness issues; NPO status and last oral intake; baseline mobility; discharge planning constraints.)

Pertinent Orthopedic History

• [Prior injury or surgery to the affected limb/joint with approximate dates]
• [Existing hardware or implants]
• [Baseline pain, function, or arthritis status]
• [Prior musculoskeletal infections]

(Include only if it materially affects diagnosis, approach, or perioperative risk; otherwise omit entire section.)

Past Medical and Surgical History

• [Comorbidities relevant to operative risk: cardiac disease, pulmonary disease, diabetes, CKD/ESRD, liver disease, bleeding disorders, prior VTE, immunosuppression, malignancy, substance use disorders with withdrawal risk]
• [Major prior surgeries, highlighting orthopedic procedures and any anesthesia complications]

Medications

• [Anticoagulants and antiplatelets with last dose timing]
• [Chronic opioids, benzodiazepines, or opioid agonist therapy]
• [Steroids or immunomodulators]
• [Diabetes medications]
• [Antibiotics already initiated with timing and indication]
• [Other medications pertinent to perioperative management]

(If medication history is unobtainable, document the reason and state that pharmacy records have been requested.)

Allergies

• [Medication allergies with reaction type]
• [Implant or material allergies relevant to planned hardware]

Social and Functional History

• [Baseline ambulation and assistive devices]
• [Living situation and support]
• [Hand dominance] (for upper extremity injuries)
• [Tobacco use]
• [Alcohol or substance use; withdrawal risk]
• [Baseline ADLs and cognitive status] (for elderly patients or hip fractures)

Family History

• [Bleeding or clotting disorders]
• [Malignant hyperthermia history]

(Include only if it changes management; otherwise omit entire section.)

Review of Systems

• Constitutional: [Fever, chills, weight loss, or denies]
• Cardiovascular/Pulmonary: [Chest pain, dyspnea, orthopnea, or denies]
• Neurologic: [Weakness, numbness, tingling, or denies]
• Skin: [Wounds, rash, or denies]
• Musculoskeletal: [Pain elsewhere, spine symptoms if trauma, or denies]

(Targeted and problem-directed; omit exhaustive negatives.)

Physical Examination

Vitals: Temp [Temperature], HR [Heart rate], BP [Blood pressure], RR [Respiratory rate], SpO2 [Oxygen saturation]

General: [Distress level, mental status, respiratory effort. Include cardiopulmonary and abdominal findings when relevant.] (If complete general exam is deferred to medicine comanagement, state this explicitly.)

Musculoskeletal Examination: [Affected region and laterality]

• Inspection: [Deformity, swelling, ecchymosis, wounds, skin tenting, surgical incision status and drainage]
• Palpation: [Point tenderness, crepitus, compartment firmness, pain out of proportion]
• Range of motion: [Active and passive ROM findings] (State if deferred with reason.)
• Motor: [Specific muscles or nerve functions tested by name]
• Sensory: [Specific nerve distributions tested]
• Vascular: [Pulses, capillary refill, temperature, Doppler findings if used]
• Special tests: [Findings] (Include only if performed.)

(For wounds or incisions, describe location, size, drainage character, surrounding erythema, fluctuance, and dressing status. For open injuries, document contamination level, exposed structures, and bleeding control.)

(If examination is limited, state the limitation and plan for repeat examination.)

Diagnostic Data Review

Labs

• [Pertinent resulted values: CBC, BMP, coagulation studies, type and screen, pregnancy test when applicable; ESR/CRP for infection; lactate if sepsis is a concern]
• [Pending studies]

Imaging

• [Modality, body part, laterality, date]: [Key orthopedic findings using appropriate terminology]. [Personally reviewed / Radiology report only.] (Note if outside images are pending upload.)

Microbiology

• [Cultures obtained with source, collection time, and results or pending status. Note any prior organism history.]

(Include Microbiology section only if cultures were obtained or are relevant; otherwise omit.)

Assessment

[1–3 sentence synthesis of the clinical picture]

1. [Orthopedic Problem 1: Diagnosis or leading differential; injury classification if applicable; urgency level]
2. [Problem 2] (Add additional problems as relevant, highest acuity first.)

Plan

[Orthopedic Problem 1]

• Operative vs nonoperative: [Decision and brief rationale; timing/urgency; anticipated procedure, laterality, and approach considerations]
• Immobilization: [Splint / cast / brace / traction; reduction status; elevation; compartment monitoring frequency if indicated]
• Weight-bearing/activity: [Status and restrictions; PT/OT consult timing]
• Pain management: [Multimodal plan]

Antibiotics and Infection Management

• [Antibiotic regimen with indication and start time; tetanus prophylaxis status; source control plan]
• [For suspected septic arthritis or PJI, document whether synovial fluid was obtained before antibiotics]

(Include only for open injuries or infection concerns; otherwise omit.)

VTE Prophylaxis

• [Mechanical / pharmacologic; hold parameters if surgery is imminent; post-op plan]

Perioperative Optimization

• [NPO status and IV fluid plan]
• [Anticoagulation or antiplatelet management: hold / reversal / bridging, or pending guidance]
• [Consults placed or planned: medicine, anesthesia, cardiology, ID, geriatrics, etc.]
• [Key medical issues requiring follow-up before OR]

Monitoring and Disposition

• [Admit location and rationale if not routine floor]
• [Neurovascular or compartment check frequency]
• [Repeat imaging or surveillance lab plan]

Patient Counseling

[Document discussion of diagnosis, treatment options, risks/benefits/alternatives; questions answered; preferences and understanding. If care declined, document refusal, understanding of risks, and return precautions.]

Procedures Performed

(Include only if a bedside procedure was performed during this encounter; otherwise omit entire section.)

[Procedure name]

• Indication: [Reason for procedure]
• Consent: [Verbal / written / implied emergent]
• Analgesia/sedation: [Agents and route]
• Technique: [Brief technique description]
• Neurovascular exam pre-procedure: [Findings]
• Neurovascular exam post-procedure: [Findings]
• Confirmation: [Post-reduction imaging / fluid analysis sent / other]
• Complications: [None / describe]