Accurate and structured clinical documentation is crucial in orthopaedics to ensure effective communication and continuity of care. The Phone Call Progress Note is a standardized format that helps orthopaedic surgeons document patient updates efficiently. Let's delve into how to correctly write and format these notes, using a detailed example for clarity.

Date and Time

Begin by specifying the date and time of the call. This ensures chronological accuracy and helps track patient progress over time. For example:

Date: 2023-10-15
Time: 14:00 - 14:30

Spoke With

This section identifies the healthcare professional you communicated with, providing context and accountability. Example:

Spoke with: Dr. Emily Carter, Orthopaedic Surgeon

Patient Reference

Include the patient's name, age, and gender. This information is essential for quick identification and reference. Example:

Re: John Doe, 45, Male

Background

Summarize the patient's relevant medical history and recent clinical events. This helps provide context for the current discussion. For instance:

• Underwent total knee replacement surgery 6 months ago

• Recent hospital presentation for knee pain and swelling

• Possible admission for further evaluation of prosthetic joint infection

Current Status

Describe the patient's current condition and treatments. This section highlights ongoing care and response to treatment. Example:

• Currently admitted for evaluation of knee prosthesis

• Receiving IV antibiotics and physical therapy

• Responding well to antibiotics, reduced swelling observed

Orthopaedic Progress

Document specific progress in the patient's orthopaedic treatment. This shows improvements and any issues that may need attention. Example:

• Engaged in daily physical therapy, improving range of motion

• Ambulating with a walker, progressing to a cane

• Wound healing well, no signs of infection

• Recent X-ray shows proper alignment of prosthesis

Plan

Outline the next steps in the patient's treatment plan. This helps guide future care and facilitates follow-up actions. Example:

• Continue IV antibiotics for 2 more weeks

• Follow-up appointment in 1 week to assess progress

• Consideration for outpatient physical therapy post-discharge

Enhancing Documentation with Notis AI Medical Scribe

Orthopaedic surgeons can significantly benefit from AI-powered medical scribes like Notis AI Medical Scribe. This tool automates and improves the documentation process, streamlining the creation of clinical notes.

Time Efficiency

By transcribing patient interactions and generating structured SOAP notes, Notis can reduce documentation time by up to 80%. This allows orthopaedic surgeons to dedicate more time to patient care, enhancing productivity and reducing burnout.

Ease of Use

Notis integrates seamlessly with WhatsApp, providing a familiar interface that requires no additional software. This ease of use makes it accessible to healthcare professionals, facilitating a smooth transition to digital documentation.

High Accuracy

With a transcription accuracy of 99%, Notis ensures that medical notes are precise and reliable. This high level of accuracy is critical in maintaining the integrity of patient documentation.

Comprehensive Documentation

Notis efficiently converts consultations into structured SOAP notes, ensuring that all relevant information is accurately captured and organized. This comprehensive approach supports effective patient charting and clinical decision-making.

In summary, the integration of AI medical scribes like Notis can revolutionize the documentation practices in orthopaedics, making the process more efficient, accurate, and less burdensome for healthcare providers.