Orthopedic Surgery Inpatient Progress Note

Date/Time: [Date and time of note]
Service: [Orthopedic Surgery, sub-service if applicable]
Author: [Name, credentials, role]
Attending of record: [Attending name]
Hospital Day: [HD #]
Post-op Day / Injury Day: [POD # or day from injury/immobilization]
Procedure/Diagnosis: [Procedure or diagnosis with laterality and date]
Weight-bearing status: [WB status and precautions]

Clinical Summary: [One-line summary with POD/HD, procedure or plan, key comorbidity only if it changes management, and current trajectory]

Subjective

[Interval history since last note] (Include overnight events or complications, pain status and response to regimen, patient-reported neurovascular symptoms, mobility progress with PT/OT, and patient concerns or barriers. If patient cannot provide history, document reason and alternate source.)

Objective

Vitals: [Relevant vital signs and trends]

I/O and Drains: [Net fluid balance, drain type/location/output/character] (State "none" if no drains present. Include Foley status only if clinically relevant.)

Labs/Imaging: [New results since last note with trends] (If none obtained, state "none.")

Exam:

• General: [Appearance and level of distress]
• Operative extremity/spine: [Focused exam findings with laterality/level specified]
• Wound/Dressing: [Incision and dressing status] (If not visualized, state why.)
• Neurovascular: [Motor function]; [Sensory findings]; [Perfusion/pulses/capillary refill] (Document explicitly; do not imply normal for elements not assessed.)
• Immobilization/Devices: [Device type, fit, alignment, skin checks] (Omit if not applicable.)
• Other systems: [Pertinent findings] (Include only if clinically indicated.)

Assessment & Plan

(Problem-oriented format by clinical priority. Include only problems actively managed or influencing care today.)

[Primary orthopedic problem: POD # s/p procedure OR nonoperative plan]

• Clinical status/trajectory: [Current status and trend]
• Activity/Mobility: [Weight-bearing status, ROM restrictions, PT/OT plan, assistive devices]
• Pain Management: [Multimodal regimen with scheduled and PRN agents, nonpharmacologic strategies, bowel regimen]
• Wound/Drains: [Dressing care schedule, drain removal criteria, suture/staple removal plan] (Omit if not applicable.)
• VTE Prophylaxis: [Agent, dose, frequency, hold parameters, discharge duration]
• Antibiotics: [Agent, indication, stop date] (Omit if not applicable.)
• Pending: [Labs, imaging, or consults pending] (Omit if none.)

[Additional active problem]

[Brief assessment of relevance to current course]

• Plan: [Actionable steps including monitoring, thresholds, medication adjustments, consults]

(Repeat for additional active problems as needed.)

Discharge Planning

• Anticipated date/destination: [Target discharge date and disposition]
• Barriers: [Current barriers] (State "none" if on track.)
• Functional milestones: [Mobility and self-care goals required for discharge]
• Discharge medications: [Medications requiring coordination: VTE prophylaxis, pain regimen, antibiotics, DME]
• Follow-up: [Clinic/provider and timeframe]
• Education: [Teaching provided and understanding confirmed]

(If discharge not imminent, summarize barriers in one line.)

(Do not copy forward drain status, weight-bearing orders, or exam findings without verifying accuracy today.)