In orthopaedic surgery, precise and comprehensive documentation is crucial for effective patient care. The New Patient Clinic Letter serves as a critical communication tool between healthcare providers, ensuring that all relevant information is captured and shared. Here’s a detailed walkthrough on how to write and format a New Patient Clinic Letter using an example template.

Begin by stating the diagnosis clearly. This section should succinctly describe the patient's primary condition. For example, "John has been diagnosed with a torn anterior cruciate ligament (ACL) in his right knee. This injury is consistent with the mechanism of injury described during his soccer match."

Outline the proposed treatment plan. This could include conservative management strategies or surgical interventions, depending on the diagnosis. For example, "We will proceed with a conservative management approach initially, including physical therapy to strengthen the surrounding muscles. If there is no improvement, we will consider surgical intervention."

Document the patient's medical history relevant to the current condition. This includes the origin and duration of symptoms. For example, "John presented with a history of right knee pain following a soccer match two weeks ago. He reports instability and swelling in the knee."

Describe any functional limitations the patient is experiencing. This information is vital for understanding the impact of the condition on the patient’s daily activities. For example, "John is unable to run or pivot on his right leg, which significantly impacts his ability to play soccer."

Summarize any treatments the patient has already received. This can include medications or therapies. For example, "John has been taking over-the-counter pain medication and has attended two sessions of physiotherapy focusing on range of motion exercises."

Provide a brief overview of the patient’s past medical and surgical history, family history, and lifestyle factors like smoking or allergies. For example, "John has no significant past medical or surgical history. He is a non-smoker and has no known allergies."

List any medications the patient is currently taking. For example, "Ibuprofen 400mg as needed."

Detail the findings from the physical examination. Include vital signs and any specific tests performed. For example, "John's vital signs are stable. On examination, there is swelling and tenderness over the right knee. The Lachman test is positive, indicating ACL instability."

Include results from any imaging studies. For example, "MRI of the right knee shows a complete tear of the ACL with associated bone bruising."

Summarize the planned management strategy, including follow-up plans. For example, "We plan to continue with physical therapy and reassess in four weeks. If there is no improvement, we will discuss surgical options."

With the increasing demand for comprehensive patient documentation, tools like Notis AI Medical Scribe can significantly enhance efficiency and accuracy in orthopaedic settings. This AI-powered virtual scribe automates the documentation process, allowing orthopaedic surgeons to focus more on patient care.

Notis reduces patient documentation time by 80%, saving clinicians up to 2 hours per day. This allows orthopaedic surgeons to dedicate more time to direct patient interactions and care.

Operating directly through WhatsApp, Notis eliminates the need for additional software, providing a familiar interface that simplifies the transition for healthcare providers.

With 99% transcription accuracy, Notis ensures that clinical notes, including SOAP notes, are captured precisely, minimizing errors in patient documentation.

Notis transforms patient consultations into structured SOAP notes instantly, streamlining the documentation process for orthopaedic specialists.

By integrating tools like Notis AI Medical Scribe into clinical practice, orthopaedic surgeons can enhance the quality of patient documentation, leading to improved patient outcomes and more efficient practice management.