Orthopedics
Orthopedic intake note template
A musculoskeletal intake structure built around mechanism of injury, objective range of motion, named special tests and a staged conservative-to-operative plan.
Best used for
- New musculoskeletal referrals
- Sports injury clinics
- Post-injury reviews
- Pre-operative assessment
Template structure
Each section shows what to document and a worked clinical example.
Mechanism, exact time of injury, immediate weight-bearing status, swelling onset, prior injury to the same joint, occupation and sporting demands.
Example
Twisting injury to right knee while playing football four days ago, felt a pop, unable to continue. Swelling within two hours. No prior knee injury. Warehouse worker.
Document inspection, palpation with named tender structures, active and passive range of motion in degrees, and the result of each special test by name.
Example
Right knee effusion present. Tender medial joint line. Active flexion 0–95 degrees, passive to 110 degrees. Lachman positive with soft endpoint, anterior drawer positive, McMurray positive medially, collaterals stable.
State imaging performed or requested and why, then give the working diagnosis with the structures implicated.
Example
Radiographs show no fracture. Clinical picture of anterior cruciate ligament rupture with probable medial meniscal tear. MRI requested.
Set out immediate management, rehabilitation, analgesia, work or sport restrictions, and the criteria that would move the patient to surgical referral.
Example
Hinged knee brace, crutches with partial weight-bearing. Physiotherapy referral for quadriceps activation. Ibuprofen 400 mg three times daily with food. Off heavy lifting for six weeks. Orthopedic surgical review once MRI reported.
Documentation tips
- Record range of motion in degrees — 'reduced ROM' is not auditable and is not comparable at follow-up.
- Name each special test and its result; this is the evidence for your diagnosis.
- Document work restrictions explicitly; these notes are frequently used for occupational and insurance purposes.
Frequently asked questions
- What must an orthopedic intake note always include?
- Mechanism of injury, neurovascular status, range of motion in degrees, named special tests, imaging performed, and functional or work restrictions.
- Why document mechanism of injury so precisely?
- Mechanism predicts the injured structures, guides imaging choice, and is often central to insurance and occupational claims.
- Can ambient AI capture range of motion?
- Only when it is spoken aloud. Clinicians who dictate measurements as they examine get them captured; otherwise the values are added during review.
- Is this template suitable for physiotherapy notes?
- The examination and staged-plan sections transfer well, though physiotherapy notes usually add treatment delivered in the session and objective progress markers.
More templates
Let ScribeMDPro draft your orthopedics notes.
Record the visit, review the draft, approve. The structure on this page is generated for you.