Orthopedic Surgery Discharge Summary

Patient: [Full name], MRN: [Medical record number], DOB: [Date of birth], Sex: [Sex]

Encounter: Facility: [Facility name], Admission date: [Admission date], Discharge date: [Discharge date], Discharge disposition: [home / SNF / inpatient rehab / LTACH / other]

Providers: Attending of record: [Name, credentials]; Orthopedic surgeon: [Name, credentials]; PCP: [Name / Not on file]

Primary Diagnosis: [Primary orthopedic diagnosis with laterality]

Brief Summary

[2–5 sentence narrative including: mechanism/context of injury or indication for surgery; primary orthopedic problem with laterality; key intervention with date and whether operative or non-operative; brief outcome statement; discharge disposition] (If procedure details are unavailable, reference the operative note by author and date rather than inferring.)

Discharge Diagnoses

• [Primary orthopedic diagnosis with laterality]
• [Secondary diagnoses that affected hospital course or discharge planning] (Include only diagnoses that directly impacted care or require post-discharge management.)
• [Hospital-acquired condition or complication, if any]

Procedures

(List each procedure on a single line. Reference the operative note for full details.)

• [Date] — [Procedure name with laterality], [Approach/site], [Operative intent]; Hardware/implants: [Brief implant summary]; Drains at discharge: [None / type and location]
• (Add additional procedures as needed.)

Key Studies & Results

(Include only studies that affect post-discharge management. Pending results belong in Follow-up section.)

• [Date] — [Pre-op imaging modality/site] — [Injury characterization with laterality]
• [Date] — [Post-op imaging modality/site] — [Alignment/hardware position assessment]
• [Date] — [Pertinent lab if relevant to outpatient care] — [Brief interpretation]

Consultations

(Include only services with recommendations that persist after discharge.)

• [Service name]: [1–3 key recommendations continuing post-discharge; specify who manages]

Hospital Course

(Organize by problem. For each: brief assessment/context, interventions, response and current status with objective anchors, discharge plan with follow-up ownership. For orthopedic problems, address neurovascular status, pain control, and mobilization milestones.)

[Orthopedic Problem: Diagnosis with laterality]

Assessment/Context: [Brief description of injury/pathology and relevant history]

Interventions: [Operative or non-operative measures performed]

Status at Discharge: [Neurovascular exam of affected limb], [Pain control approach and adequacy], [Mobilization milestones: bed mobility, transfers, ambulation distance/assist level], [Post-op day, imaging status, drain status]

Discharge Plan & Ownership: [Outpatient actions, responsible provider, and timing]

[Additional Problems]

(Add sections for medical problems or comorbidities that impacted care, following same format: assessment, interventions, status, discharge plan with ownership.)

Complications

[Complication]: [Evaluation performed], [Intervention], [Status at discharge], [Required follow-up and responsible service] (If none occurred, state: No complications during hospitalization.)

Condition at Discharge

[Vital signs or "Hemodynamically stable"], [Wound/incision status: clean/dry/intact vs drainage], [Limb neurovascular exam for affected extremity], [Splint/cast/brace status if applicable], [Functional status and mobility level with assistance required] (If not examined by discharging clinician, reference the most recent documented exam with date.)

Disposition, Services & Equipment

• Destination: [Home / SNF / inpatient rehab / LTACH / other]
• Home health services: [Nursing / PT / OT / none]
• Durable medical equipment: [Walker / crutches / wheelchair / brace type / CPM / wound vac supplies / other]

Activity Restrictions & Rehabilitation

(This section is mandatory. Do not infer weight-bearing status; if not documented, include placeholder requiring surgeon confirmation.)

• Weight-Bearing Status: [Affected limb]: [NWB / toe-touch only / partial WB with specific limit / WBAT] (If unspecified: Surgeon confirmation required before discharge.)
• Range of Motion & Precautions: [ROM limits with timeframes], [Surgical approach precautions], [Lifting restrictions]
• Immobilization/Brace: [Type], [When to wear], [Removal rules for hygiene/therapy]
• Therapy Plan: [PT/OT frequency and setting], [Goals], [Home exercise program]
• Driving: [Restrictions: no driving while on opioids / until off immobilization / until cleared by surgeon]

Wound Care

• Dressing: [Type], [Change frequency], [Keep dry vs may shower with protection]
• Bathing: Showering allowed [date/criterion]; No soaking/submersion until [date/criterion]
• Incision Care: [Care instructions], [When to remove steri-strips if applicable]
• Sutures/Staples: Removal by [clinic / home health] on [timeframe, e.g., POD 10–14]
• Drains/Wound Vac: (If present at discharge) [Device and settings], [Output monitoring], [Troubleshooting], [Contact for issues]
• Warning Signs: [Infection signs: fever threshold, redness, warmth, purulent drainage, dehiscence]

VTE Prophylaxis

• Pharmacologic: [Agent] [Dose] [Route] [Frequency]; Start: [Date]; Stop: [Date or duration] (If regimen not finalized, insert placeholder requiring resolution before signing.)
• Mechanical: [Compression stockings / IPC] — [Wear schedule] (If applicable)
• Management Ownership: Adjustments managed by [orthopedics / PCP / anticoagulation clinic]
• Warning Signs: DVT: [calf/thigh pain, unilateral swelling, warmth]; PE: [shortness of breath, chest pain, hemoptysis]; Bleeding: [signs and when to seek care]

Discharge Medications

Allergies: [Drug and reaction / NKA]

Medication Changes: New: [List]; Changed: [List]; Stopped: [List with reasons if clinically important]

• [Medication] — [Dose] — [Route] — [Frequency] — [Indication] (Include stop date for time-limited medications.)
• (List all reconciled medications.)

Opioid Counseling: (If prescribed) [Daily maximum], [Taper expectation], [Constipation prophylaxis], [No driving/alcohol]

Anticoagulant Counseling: (If prescribed) [Bleeding precautions], [Drug interactions], [When to seek care]

Follow-up & Pending Results

• Appointments: [Specialty/Provider] — [Timeframe or date] — [Purpose]
• Surveillance: [Repeat imaging timing], [Lab monitoring plan], [Who reviews results]
• Pending Results: [Test name], obtained [Date], followed by [Responsible clinician], patient notified via [Method] (If none: Pending results: none.)
• Scheduling: (If not yet scheduled) [Who will schedule], [Contact information if patient must schedule]

Return Precautions

• Wound/Infection: Fever ≥[temperature threshold], increasing redness, warmth, swelling, purulent drainage, wound dehiscence
• DVT: New/worsening calf or thigh pain, unilateral swelling, warmth, redness
• PE: Sudden shortness of breath, chest pain, hemoptysis, syncope
• Neurovascular Compromise: Numbness/tingling, pain out of proportion, pallor/coolness, color change, inability to move digits
• Medication Issues: Uncontrolled pain, opioid side effects, bleeding/bruising on anticoagulants
• Contact: Clinic: [Phone number] during business hours; After-hours: [Instructions/number]; Call 911 for severe chest pain, severe shortness of breath, or limb-threatening emergency