Orthopedic SOAP Note Medical Transcription Sample Reports
Orthopedic SOAP Note Medical Transcription Example 1
SUBJECTIVE: The patient presents for followup regarding his right hip injury. He is approximately 6 weeks status post repair of a right femoral neck fracture with sliding hip screw. He has been attending outpatient physical therapy. He denies any hip, groin, trochanteric or buttock pain at the present time. He has had some right-sided axial low back pain without any radicular symptoms over the past week. He has been working on this with the physical therapy team.
OBJECTIVE: On examination of the right hip, the surgical skin incision is healed. There are no local signs of infection. The foot is warm and well perfused with brisk capillary refill. Sensation is intact to light touch distally. There is no pain with passive range of motion of the right hip, knee or ankle. There is no tenderness to palpation over the trochanter. His gait is examined and it is nonantalgic in nature.
Radiographs of the right hip demonstrate no change in fracture alignment or implant position.
ASSESSMENT AND PLAN: Status post percutaneous stabilization with sliding hip screw of right valgus impacted femoral neck fracture. The diagnosis was described in detail to the patient. At the present time, the patient continues to improve clinically. We would like him to continue with outpatient physical therapy. He does work a job that requires significant walking, and we feel that he will require additional therapy prior to returning to work. We will see him back in approximately 6 weeks’ time for repeat clinical reevaluation with AP and cross-table lateral radiographs of the right hip.
Orthopedic SOAP Note Medical Transcription Example 2
CHIEF COMPLAINT: Right hip pain.
SUBJECTIVE: The patient is a right-hand dominant, previously community ambulatory male with a past medical history significant for actinic keratosis, dyshidrotic eczema and bolus pemphigus, who sustained a fall from a standing height earlier this morning. He slipped while chasing his dog, falling directly onto his right hip. He had immediate hip and groin pain. He was unable to bear weight. He was taken to the hospital and diagnosed with a right nondisplaced femoral neck fracture. He denies any antecedent hip pain. He denies any other orthopedic symptoms.
OBJECTIVE: Vital Signs: Stable. On examination of the right lower extremity, there is no clinical deformity. The foot is warm and well perfused with brisk capillary refill. Sensation is intact to light touch in the distribution of the sural, saphenous, superficial peroneal, deep peroneal and tibial nerves. He is able to actively dorsiflex and plantarflex the foot and toes against gravity. There is no calf pain, swelling or tenderness to palpation. He is unable to perform a straight leg raise against gravity. There is no tenderness to palpation over the foot, ankle, leg or knee. With a gentle passive range of motion of the right hip, there is reproducible groin pain. There is tenderness over the portion of the trochanter. The foot is warm and well perfused with brisk capillary refill.
Radiographs of the pelvis and right hip, as well as a CAT scan of the right hip, demonstrate a valgus impacted femoral neck fracture. There is no evidence of osteonecrosis. There is evidence pre-existing osteoarthritis on the right hip.
ASSESSMENT AND PLAN: Nondisplaced right femoral neck fracture. The diagnosis was described in detail to the patient. Treatment options were discussed in detail including nonoperative versus operative treatment and the risks and benefits associated with both. We explained that in order to best relieve his pain and to give him the best chance of restoring preinjury level of mobility and function, that surgery is indicated, specifically closed, possible open reduction and internal fixation of the right femoral neck fracture. We explained that this is a life-altering injury, which will have an effect not only on his hip function and ability to walk but his overall health as well. He understood the above. Risks of the planned surgical procedure were reviewed in detail, but not limited to bleeding, hematoma, wound healing problems, infection, loss of fixation, implant failure, painful hardware requiring removal, peri-implant fracture, delayed union, nonunion, malunion, posttraumatic arthritis, nerve injury, vascular injury, blood clots, lung clots, cardiac problems, respiratory problems, disability, limp, rotational abnormalities of the lower extremity including potentially death. He understood the above and consent was willingly obtained.
Orthopedic SOAP Note Medical Transcription Example 3
SUBJECTIVE: The patient presents for followup regarding his right hip. He is approximately 10 weeks status post ORIF of a right femoral neck fracture. Overall, he has been doing quite well. He has discontinued the use of the cane. He does not have any activity-related pain. He does have some hip stiffness after prolonged sitting. Otherwise, he denies any other pain or mechanical symptoms.
OBJECTIVE: On examination of the right hip, the surgical incision is healed. There are no local signs of infection. The foot is warm and well perfused with brisk capillary refill. Motor and sensory functions are intact distally. There is no pain with passive range of motion of the right foot, ankle or knee. There is no reproducible groin pain with passive range of motion of the right hip. There is mild trochanteric discomfort upon palpation.
Radiographs of the right hip demonstrate no change in fracture alignment or implant position. There is no evidence of osteonecrosis.
ASSESSMENT AND PLAN: Status post percutaneous stabilization with a sliding hip screw of right valgus impacted femoral neck fracture. The diagnosis was described in detail to the patient. At the present time, the patient continues to improve clinically. He has no restrictions. He will return to work on MM/DD/YYYY, full duty. We will see him back in 3 months’ time for repeat clinical reevaluation with AP and cross-table lateral radiographs of the right hip.
Orthopedic SOAP Note Medical Transcription Example 4
SUBJECTIVE: The patient presents in followup regarding her left foot injury. She is approximately 12 weeks status post open reduction and internal fixation of the left tarsometatarsal dislocation. She has been in a tall Aircast walker boot and for the most part has remained nonweightbearing. She reports no problems with swelling. She continues to have intermittent swelling involving the great toe on the left foot. She denies any fevers or chills.
OBJECTIVE: On evaluation of the left foot and ankle, the skin is intact. Surgical incisions are well healed. There are no local signs of infection. There is minimal soft tissue swelling. Sensation is intact to light touch distally. The foot is warm and well perfused with brisk capillary refill. There is no calf pain distally on palpation. She is able to actively dorsiflex and plantarflex the foot and toes against gravity. The skin is intact over the great toe. There is no surrounding warmth, erythema. There is moderate amount of soft tissue swelling. There is no active drainage.
Radiographs of the left foot demonstrate no change in position of the tarsometatarsal joints or the hardware. There is no change in the chronic inflammatory destructive changes involving the great toe, distal phalanx.
ASSESSMENT AND PLAN:
1. Status post open reduction and internal fixation, left tarsometatarsal dislocation.
2. Chronic osteomyelitis, distal phalanx, great toe.
The diagnosis was described in detail to the patient. At the present time, she may advance to weightbearing as tolerated and may transition out of the tall Aircast walker boot. With regard to her great toe condition, this is most likely chronic osteomyelitis with intermittent wound drainage. Currently this sealed off. She has been on Augmentin in the past. We would like to obtain an MRI just to confirm the diagnosis. Treatment options were discussed, including medical and surgical and the alternatives including no treatment. Medical treatment would be chronic suppression with antibiotics and surgical treatment would be an amputation. She understands the above. She will return after the MRI is completed. We have given her a prescription for Augmentin in the meantime.
Orthopedic SOAP Note Medical Transcription Example 5
SUBJECTIVE: The patient returns in followup regarding her left tarsometatarsal dislocation. She is approximately 8 weeks status post open reduction and internal fixation of the left tarsometatarsal dislocation. She has been in a short-leg nonweightbearing cast. For the most part, she has been compliant with the nonweightbearing protocol; although, she states that she has placed some weight on it from time to time. She has no pain at this point. She denies any skin irritation at the edges of the cast. She denies any heel or calf pain. She has been taking enteric-coated aspirin for venous thrombus and prophylaxis.
OBJECTIVE: On examination of the left foot and ankle, the cast is removed. The skin is examined. The skin is circumferentially intact. Surgical incisions are healed with no local signs of infection. The forefoot pins are clean, dry and intact with no local signs of infection. The forefoot pins were removed in the office today. Sensation is intact to light touch distally. She is able to actively flex and extend the toes against gravity.
Radiographs of the left foot demonstrate no change in fracture alignment or implant position.
ASSESSMENT AND PLAN: Status post open reduction and internal fixation of left tarsometatarsal fracture dislocation. The diagnosis was reviewed in detail with the patient. At the present time, these wounds remain stable and her forefoot pins were removed. She tolerated this well. She is placed into a tall Aircast walker boot. She is instructed to remain strictly nonweightbearing on the left lower extremity. We will see her back in 4 weeks’ time for repeat clinical and radiograph evaluation with 3 views of the left foot to be taken out of the boot. If there are any problems prior to this appointment, she will give us a call.
Orthopedic SOAP Note Medical Transcription Example 6
SUBJECTIVE: The patient presents along with her daughter in followup regarding her left foot injury. She is postoperative day #20, status post open reduction and internal fixation of left tarsometatarsal fracture dislocation. She has been in a well-padded short-leg nonweightbearing cast and has been compliant with the nonweightbearing protocol. She is taking Coumadin for venous thromboembolism prophylaxis. She reports no calf pain, heel pain or irritation at the edges of the cast. She has finished her course of Augmentin for left great toe paronychia.
OBJECTIVE: On evaluation of the left foot and ankle, the cast was removed. The skin was examined. The surgical incision was healed with no local signs of infection. Sutures removed. Steri-Strips were applied to the wound. There was minimal soft tissue swelling. The pin sites were clean, dry and intact with no local signs of infection. There was no calf pain, swelling or tenderness to palpation. She was able to actively dorsiflex and plantarflex the foot and toes against gravity. The great toe paronychia lesion was healed. There were no local signs of infection.
Radiographs of the left foot demonstrate no change in fracture alignment or implant position.
ASSESSMENT AND PLAN: Status post open reduction and internal fixation, left tarsometatarsal fracture dislocation. The diagnosis was described in detail to the patient and the patient’s daughter. After clinical and radiograph evaluation, the third tarsometatarsal pin was removed as at this point we feel it is not adding any additional stability. The patient tolerated the procedure well. She was placed into a well-padded short-leg nonweightbearing cast with the ankle in neutral dorsiflexion. She would discontinue the Coumadin and begin aspirin 325 mg once daily for venous thromboembolism prophylaxis. We expressed the importance of remaining strictly nonweightbearing on the left lower extremity. We will see her back in 2 weeks’ time for repeat clinical reevaluation with 3 views of the left foot to be taken with the cast removed. She understands the treatment plan as outlined above.
Orthopedic SOAP Note Medical Transcription Example 7
SUBJECTIVE: The patient presents for followup regarding his right foot injury. He is approximately 11 months status post open reduction and primary tarsometatarsal fusion for right Lisfranc fracture dislocation. He has been weightbearing as tolerated. He has resumed all preinjury activities. He has occasional discomfort in the foot but this has not limited his activities. He denies any swelling.
OBJECTIVE: On examination of the right foot and ankle, the skin is circumferentially intact. Surgical incisions are well healed with no local signs of infection. Sensation is intact to light touch distally. He is able to actively dorsiflex and plantarflex the foot and toes plantarflex. He is able to actively dorsiflex to 5 degrees, plantarflex to 45 degrees. There is no tenderness to palpation of the forefoot, midfoot or hindfoot. His gait is examined. It is nonantalgic in nature. He does not walk with a limp.
Radiographs of the right foot demonstrate no change compared to previous radiographs taken in June of this year.
ASSESSMENT AND PLAN: Status post open reduction and primary tarsometatarsal fusion for right Lisfranc fracture-dislocation. The diagnosis was described in detail to the patient. At the present time, the patient is doing well from a functional standpoint. He has no restrictions at this point. We have encouraged him to continue with his home exercise program. We would like to see him in 12 months’ time for repeat clinical reevaluation with weightbearing, AP, lateral oblique radiographs of the right foot. If there are any problems prior to the next appointment, he will give us a call. He understands treatment plan as outlined above.
