Orthopedic Surgery Preoperative Planning Note

Date/Time: [Date and time]
Location: [Clinic / pre-admission testing]
Patient: [Full name]
DOB: [Date of birth]
MRN: [Medical record number]
Surgeon: [Surgeon name, credentials]
Planned Procedure: [Standardized procedure name with explicit laterality/site] (Required field)
Primary Diagnosis: [Primary orthopedic diagnosis with explicit laterality]
Referring/Primary Care Clinician: [Name, role, contact] (Include only if applicable)

(This is an orthopedic surgery preoperative planning note. It is not an operative report and should not duplicate anesthesia pre-op evaluation content. Document laterality and the planned procedure explicitly throughout. The consent discussion must be documented or explicitly noted as deferred.)

Preoperative Planning Summary

[1–3 sentence synthesis: diagnosis with laterality and functional impact, decision to proceed after failed conservative care, key optimization needs or pending clearances]

Chief Complaint

[Patient-stated reason for visit with laterality] (Use patient's own words in quotes when helpful.)

History of Present Illness

[Narrative HPI: onset, duration, trajectory, severity; mechanical symptoms or instability if relevant; functional impact on walking, stairs, ADLs, sleep, work, sport; prior injuries and surgeries to same limb/joint/spine; red flags if present; patient goals and rationale for surgery now] (For follow-up visits after prior surgical decision, provide focused interval history describing changes since last visit.)

Prior Conservative Management

• [Activity modification: dates, description, response]
• [Physical therapy: dates, duration, adherence, outcomes]
• [Medications tried: agent, duration, response]
• [Injections: type, date(s), duration of relief]
• [Bracing/orthotics: type, duration, response]
• [Specialist consultations: discipline, date, recommendations]
• [Summary of what failed and what was learned]

(If conservative care was not attempted, state why: e.g., displaced fracture, mechanical failure, urgent indication. This documentation establishes medical necessity for elective procedures.)

Relevant Medical and Surgical History

• [Comorbidities impacting anesthesia, wound healing, or thrombosis risk]
• [Prior surgeries relevant to planned anatomy/approach]
• [Bleeding/clotting history and anticoagulant/antiplatelet use]
• [Infection history: prior joint infection, MRSA/MSSA colonization]
• [Allergies: antibiotics, latex, metal if implants planned]
• [Implantable devices: pacemaker/ICD, spinal cord stimulator]

(Include only pertinent positives and negatives affecting surgical decision-making.)

Medications

• [Anticoagulants/antiplatelets: agent, indication; perioperative plan status: determined / pending coordination with prescriber / pending anesthesia]
• [Diabetes medications: agent; perioperative plan status and coordinating service]
• [Chronic steroids or immunosuppressants: agent, dose; plan status and owner]
• [Chronic opioids: current regimen; perioperative pain coordination plan and owner]
• [Other medications requiring perioperative coordination]

(Do not document that a medication will be held unless you are responsible for that decision.)

Social and Functional History

• [Tobacco/nicotine: type, quantity, cessation status]
• [Alcohol use: quantity, frequency]
• [Home environment and caregiver support]
• [Baseline mobility, assistive devices, fall history]
• [Work demands and anticipated time off] (Include when relevant.)
• [Discharge planning considerations for same-day or outpatient pathway]

Physical Examination

(Document only elements actually examined. If exam is limited, state why.)

• [Vital signs] (Include only if obtained.)
• [General appearance]
• Operative site examination:
  • [Inspection: skin integrity, prior incisions, swelling/effusion, deformity]
  • [Palpation: tenderness location, warmth]
  • [Range of motion: active/passive with quantified degrees]
  • [Stability and special tests relevant to joint/region]
  • [Strength of key muscle groups]
  • [Neurovascular status: sensation, motor, pulses]
  • [Gait and assistive device]
  • [Contralateral comparison] (Include if clinically meaningful.)

Diagnostics Reviewed

• [Imaging: modality, body part, laterality, date, source]
  • [Radiology report: key findings]
  • [Surgeon's interpretation and clinical correlation]
• [Relevant laboratory results: test, date, result] (Include only if pertinent.)
• [Pending studies and contingency plan] (If imaging unavailable, document that plan is provisional pending review.)

Assessment

• [Primary orthopedic diagnosis with laterality]: [1–2 sentence synthesis linking symptoms, examination, imaging, and failed conservative care to surgical indication]
• [Secondary diagnoses affecting surgical plan or risk: e.g., deformity, osteoporosis, obesity, tobacco use disorder, diabetes, chronic opioid use]

Surgical Plan

• Procedure: [Standardized name with explicit laterality/site] (Required field.)
• Approach/technique: [High-level description]
• Setting: [Inpatient / outpatient]; anticipated LOS: [duration]
• Anesthesia: [Anticipated type if known] (Do not duplicate anesthesia evaluation.)
• Special equipment: [Navigation / robotics / fluoroscopy / other] (Include if applicable.)
• Decision status: [First decision for surgery at this encounter / previously decided]
• Patient elects to proceed after counseling.

Implant and Equipment Plan

(Include this section when implants or specialized hardware are planned.)

• [Implant system/vendor if predetermined]
• [Fixation strategy: cemented / cementless; locking / nonlocking] (When relevant.)
• [Templating status; sizing to be determined intraoperatively unless templated]
• [Contingency plans: backup implants, revision tray availability, alternative constructs]
• [Decision framework if implant choice depends on intraoperative findings]

Informed Consent Discussion

[Document consent discussion: nature and purpose of procedure discussed; expected benefits with realistic framing; alternatives discussed including continued nonoperative care, injections, bracing, no treatment; material risks tailored to procedure and patient factors discussed including infection, bleeding, neurovascular injury, stiffness, DVT/PE, anesthetic complications, hardware failure, need for revision, persistent symptoms; patient had opportunity for questions; patient verbalized understanding; decision made] (Note interpreter use if applicable. If consent deferred, document reason and plan for completion.)

Perioperative Optimization Plan

(For each item, document status: [Completed / Ordered / Pending / Not indicated] and owner for pending items.)

• Medical clearance: [Specialist, indication, status, findings]
• Dental clearance: [Status] (Per arthroplasty protocol if applicable.)
• Diabetes optimization: [A1c value/date, target, status, plan]
• Tobacco/nicotine cessation: [Status, counseling provided, verification plan]
• Anemia evaluation: [Hgb value/date, status, plan]
• Skin optimization: [Findings near incision site, interventions, status]
• Infection screening: [MRSA/MSSA status, decolonization instructions if positive]
• Sleep apnea: [OSA status, CPAP plan]
• VTE prophylaxis: [Agent, duration, risk factors considered]
• Antibiotic prophylaxis: [Considerations including allergies, MRSA history]
• Chronic pain management: [Baseline regimen, perioperative plan, coordinating service]

Postoperative Pathway

• Weight-bearing: [WBAT / partial / TTWB / NWB; duration]
• Immobilization/bracing: [Type, duration, weaning criteria]
• PT/OT: [Timing, setting: home health / outpatient]
• DME needs: [Walker, crutches, raised toilet seat, etc.]
• Follow-up: [Initial visit timing, subsequent intervals]
• Return precautions: [Symptoms warranting urgent evaluation]

(If restrictions contingent on intraoperative findings, document decision framework.)

(If information is missing but required for safety, insert placeholder: [ACTION NEEDED: item, responsible party, due date]. Omit sections not applicable rather than leaving empty.)