Orthopedic Surgery Outpatient Progress Note

Date of Service: [Date of service]

Patient: [Patient name / identifier]

Provider: [Provider name, credentials]

Visit Type: [new / established]; [post-op / non-post-op]

Chief Complaint

[Primary reason for visit with anatomic location and laterality] (For post-op visits, include procedure name and date.)

History of Present Illness

[History of Present Illness] (Write a focused paragraph. For new problems: onset and mechanism, precise location with laterality, pain character and severity, functional impact on ADLs/work/sport, prior treatments including PT/medications/injections/imaging, and patient goals. For established or post-op visits: emphasize interval change, treatment response, new symptoms, and current function. Omit elements that do not apply. Document clinically relevant unknowns explicitly.)

Pertinent History

[Relevant medical/surgical history, prior surgeries on the affected region, current medications especially anticoagulants and NSAIDs, allergies] (Include only what materially affects today's evaluation or plan. Omit section if nothing pertinent beyond the problem list.)

Objective

Vitals: [Relevant vitals if obtained]

Exam: [Focused MSK and neurovascular examination of the affected region including inspection, range of motion, strength, stability/ligamentous testing, provocative/special tests by name and result, and distal neurovascular status. For spine complaints, include neurologic screening of myotomes, dermatomes, and reflexes. Note any exam limitations such as pain, guarding, or post-op restrictions.]

Imaging: [Studies reviewed with modality, laterality, date, and source; clinician interpretive summary of key findings with clinical correlation. Note if outside images unavailable when relevant.]

Assessment

(Problem-oriented list. For each problem, state diagnosis with laterality and chronicity, synthesize supporting findings, and note severity/stage when it drives management.)

[Problem 1: Diagnosis with laterality]

[Supporting findings from history, exam, and imaging; severity/stage; differential if uncertainty remains]

[Problem 2: Diagnosis with laterality]

[Supporting findings] (Add problems as needed; omit if single problem.)

Plan

[Problem 1]

[Management plan addressing relevant elements: activity modification, PT referral with focus and precautions, medications, bracing/DME, work/sport restrictions. If injection discussed: indication, expected benefit, risks, patient decision. If surgery discussed: indications, proposed procedure, alternatives, material risks, patient decision. Follow-up timing, purpose, and return precautions.] (Include only applicable elements.)

[Problem 2]

[Management plan as above] (Add problems as needed; omit if single problem.)

Procedure Note

(Include only if a procedure was performed today.)

Procedure: [Procedure name and laterality]

Indication: [Clinical indication]

Consent: [Informed consent obtained; risks/benefits/alternatives discussed]

Technique: [Sterile prep, approach, guidance if used, needle size, landmarks]

Medications: [Agent(s) with dose/volume]

Outcome: [Patient tolerance, immediate response, complications if any]

Post-Procedure Instructions: [Aftercare, activity restrictions, warning signs, follow-up]