Orthopedic Surgery Consultation Note (Inpatient)

Date/Time of Note: [Date and time of documentation]

Date/Time Patient Seen: [Date and time patient evaluated by orthopedics]

Location: [ED / floor / ICU]

Requesting Service/Clinician: [Service and clinician name]

Patient Identifiers: [Per institutional standard]

Reason for Consult

[Specific consult request as short phrase] for [explicit clinical question(s) to be answered]. [Transfer of care / Comanagement / One-time consultation]. Urgency: [routine / urgent / emergent].

Patient Summary

[One to two sentence summary: age, key comorbidities affecting orthopedic decisions, mechanism and timing of injury, affected site with laterality, current neurovascular and wound status]. (If history obtained from collateral source, note: [patient / family / EMS / outside records / unable to obtain due to: reason].)

History of Present Illness

[Chronological narrative beginning with mechanism and timeline: exact or best-estimate time of onset/injury; mechanism; laterality and anatomic location; prehospital care/immobilization; prior reductions or manipulations and response; pain character and functional status since injury; neurovascular symptoms including numbness, weakness, coolness, color change. For wounds: open vs closed, contamination type, time exposed. For postoperative issues: index procedure, date, surgeon/facility, implant details, post-op course including antibiotics and timeline of drainage/erythema/fever. For suspected infection: fever/chills, joint effusion, recent bacteremia, immunosuppression. Red flags when present: compartment syndrome concern, open fracture concern, vascular compromise, septic joint concern.] (If critical details unavailable, state "Unknown" or "Unable to obtain due to [reason]"—do not infer time of injury, anticoagulant status, tetanus status, or antibiotic administration.)

Relevant History

PMH: [Conditions affecting management: diabetes, PVD, neuropathy, CKD/dialysis, osteoporosis, prior VTE, immunosuppression]

PSH: [Prior operations on affected extremity, arthroplasty, ORIF, relevant spine surgery]

Medications: [Anticoagulants/antiplatelets with last known dose; chronic steroids; DMARDs/biologics; antibiotics already given this encounter; analgesics received]

Allergies: [Allergies with reaction type] (Do not state NKDA unless explicitly confirmed.)

Baseline Function: [Ambulation status, assistive devices, living situation, hand dominance for upper extremity, tobacco use] (Include only if relevant to decision-making.)

Physical Examination

Vitals/General: [Vitals] [General appearance: distress level, mental status, overall trauma burden]

Inspection/Skin/Soft Tissue: [Deformity, swelling, ecchymosis, skin compromise. Wounds: location, size, contamination, exposed bone, blistering. Post-op site: incision appearance, drainage character/amount, dehiscence. Compartments: soft vs tense; pain with passive stretch.] (If unable to assess, state "Not assessed—reason: [specify]".)

Palpation/ROM: [Tenderness localization. Active and passive ROM findings.] (If ROM deferred, state reason.)

Neurovascular Examination: (Do not abbreviate to "NVI" alone. Document specific findings for each element tested.)

• Vascular: [Named pulses assessed] [Capillary refill] [Temperature] [Color] [Comparison to contralateral side]
• Motor: [Strength by nerve distribution using 0–5 scale] [Comparison to contralateral side] (If limited, document reason.)
• Sensory: [Sensation by nerve distribution: light touch/pinprick] [Comparison to contralateral side]

Special Tests: [Ligamentous tests, tendon integrity, extensor mechanism, other region-specific tests] (Include only if performed.)

Pre-Intervention NV Status: [Time] [Detailed NV findings immediately prior to intervention] (Include only if intervention performed.)

Post-Intervention NV Status: [Time] [Detailed NV findings immediately after intervention] (Include only if intervention performed.)

Imaging

• [Modality, body part with laterality, date, views]: [Personally reviewed images / Reviewed radiology report only]. [Orthopedic interpretation: fracture/dislocation pattern, displacement/angulation/shortening, articular involvement, comminution, alignment after reduction, hardware assessment, signs concerning for infection].
• [Additional study if applicable]: [Personally reviewed images / Reviewed radiology report only]. [Findings / Pending].

Pertinent Labs

(Include only relevant categories; omit section entirely if no labs pertain.)

• Trauma/Operative Planning: [CBC, BMP, coagulation studies, type and screen with values; "Pending" if not resulted]
• Infection Workup: [WBC, ESR, CRP, synovial analysis, cultures with source and collection time; note antibiotics already given]
• Compartment/Rhabdomyolysis Concern: [CK, lactate, myoglobin, urinalysis]

Assessment

(List problems in order of severity/urgency. Do not list diagnoses not addressed in the plan.)

• [Problem 1]: [Diagnosis with laterality and anatomic specificity; classification: open vs closed, Gustilo-Anderson grade if open, periprosthetic, septic arthritis; current NV status; soft-tissue condition; operative vs nonoperative consideration]
• [Problem 2]: [As above, if applicable]

Plan

Global Recommendation: [Operative / Nonoperative] management; [emergent / urgent / semi-urgent / elective] timing; Admission to [Orthopedics / Medicine / Trauma / Other]; Weight-bearing: [NWB / TDWB / PWB / WBAT] [specify extremity].

• [Problem 1] – Immediate Actions: [Reduction, splint type/position, elevation, ice, analgesia. Antibiotics: agent, dose, timing. Tetanus: up to date / booster given / unknown. NPO status. Compartment check frequency. Neurovascular check frequency.]

• [Problem 1] – Operative Plan: [Proposed procedure, indication, timing/urgency, prerequisites, perioperative risk considerations, antibiotic plan, DVT prophylaxis.] (Include only if operative management recommended.)

• [Problem 1] – Nonoperative Plan: [Immobilization type/position, activity and weight-bearing restrictions, wound care, therapy needs, follow-up imaging timeline, return precautions.] (Include only if nonoperative management recommended.)

• [Additional Problems]: [Structured similarly with actionable steps for non-orthopedic teams.]

• Consults/Coordination: [Additional consults needed: vascular, plastics, ID, anesthesia, medicine, rehab. Monitoring location.] Orthopedic follow-up: [Ortho will follow daily / Ortho will follow PRN—call for: specific concerns / No further inpatient ortho, clinic follow-up in X weeks].

Communication

Recommendations communicated to [name and role] via [in-person / phone / secure message] at [time]. [Shared decision-making discussion: risks/benefits/alternatives discussed with patient/family; patient preferences; refusals with direct quotes if applicable.] Disposition: [admission service, OR booking status, anticipated timing, outpatient follow-up plan].

Procedure

(Include only if bedside procedure performed during consult: reduction, splint/cast, aspiration, wound irrigation, traction pin.)

• Procedure: [Name] for [indication]
• Consent: [Written / Verbal / Emergent exception] obtained from [patient / surrogate]
• Anesthesia: [Local/regional block type / Procedural sedation: agents, managed by service]
• Technique: [Brief key steps]
• Findings/Specimens: [Intra-procedural findings. For aspirations: volume, appearance, tests sent]
• Complications: [None / Description]
• Post-Procedure Status: [Patient tolerance, immobilization applied, post-procedure imaging ordered]. Post-Procedure NV Exam: [Time] [Detailed neurovascular findings]