Orthopaedics template
Orthopaedics notes, written while you talk
Fracture and joint clinics need mechanism, side and a structured examination. The Orthopaedics template records all three, plus neurovascular status, imaging and the effect on work and daily life.
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Built for a Orthopaedics clinic
The consultations this template is laid out for, among others:
- Ankle and wrist injuries
- Fracture clinic follow-up
- Knee pain
- Low back pain
- Shoulder pain
- Osteoarthritis
See a Orthopaedics note
A short consultation in Urdu, and the note Hikayat Scribe writes from it.
The consultation (Urdu)
Patient: Kal cricket khelte hue left ankle mud gaya.
Doctor: Chal sakte hain?
Patient: Mushkil se.
Doctor: Left lateral malleolus pe soojan aur tenderness hai. X-ray karwate hain. Ice aur elevation.
The note
- Mechanism of injury
- Inversion injury, left ankle, playing cricket yesterday.
- Musculoskeletal examination
- Swelling and tenderness over the left lateral malleolus.
- Function
- Walking with difficulty.
- Plan
- X-ray left ankle. Ice and elevation.
Fictional patient. Sections that were not discussed are left off.
What the Orthopaedics template records
Alongside the usual history and examination, every Orthopaedics note has these sections:
Only what was discussed
Left and right are always recorded exactly as said, and the note never reads "neurovascularly intact" unless you checked and said so. Any section that was not covered is simply left off the note, so it never fills up with "not discussed".
Set it once
Choose Orthopaedics when you start a clinic or ward note, or tick "Always start my notes with this specialty" and it stays selected until you change it. Specialty templates are part of Pro and Enterprise, and included in the 7-day free trial.
The rest of the note
- Ranked differentials with the reasoning shown, for you to choose from
- Investigations and medicines you tick yourself; nothing is prescribed until you do
- ICD-10 and SNOMED codes for your review
- Your name, qualifications, registration number and the date and time on the printed note
How it works
- Record. Press the button and talk with your patient in any of nine languages, or dictate on your own.
- Review. The note is ready in seconds. Tick the diagnosis, investigations and medicines you are keeping, and edit anything.
- Use it. Copy, print or email the note, with your name, qualifications and registration number on it.
Common questions
- Will it write "neurovascularly intact"?
- Only if you checked and said so. In this example nothing was said, so the section is left off.
- How does it handle left and right?
- The side is always recorded exactly as said, in every section.
- Can I use the Orthopaedics template for ward notes?
- Yes. Specialty templates work for outpatient clinic notes and inpatient ward notes.
- What if I also have my own template?
- Both are used together: your own sections first, then the specialty sections.
Related
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