Clinical documentation is a critical component of patient care, particularly in orthopaedics where detailed records support treatment decisions and continuity of care. This guide walks you through the correct writing and formatting of an orthopaedic progress note using a structured template, followed by an exploration of how AI medical scribes like Notis can streamline this process.

Understanding the Orthopaedic Progress Note Template

The orthopaedic progress note is a comprehensive document that follows the SOAP (Subjective, Objective, Assessment, and Plan) format. This structure ensures that all relevant patient information is captured systematically, facilitating clear communication among healthcare providers.

Subjective Section

The subjective section captures the patient's perspective on their condition. For example, a 45-year-old male patient might report persistent joint pain and stiffness, particularly in the mornings, following a knee arthroscopy. He might note some improvement in range of motion thanks to physiotherapy but still experience limitations in movement. This narrative provides insight into the patient's experience and progress since the last consultation.

Objective Section

This section includes measurable data and observations made during the physical examination. Key details might include vital signs such as blood pressure of 120/80 mmHg and heart rate of 72 bpm. A physical examination could reveal mild swelling and tenderness around the knee, with restricted range of motion. Imaging results, such as a recent MRI showing mild effusion with no significant structural damage, are also documented here. These objective findings support the clinical assessment.

Assessment & Plan Section

The assessment evaluates the gathered information to identify the patient's condition. For instance, post-arthroscopy knee pain might be attributed to post-operative inflammation and stiffness. The plan outlines the proposed management strategy, which could involve continuing physiotherapy, prescribing NSAIDs for pain, and scheduling a follow-up. It might also note that no further investigations or surgical interventions are required, emphasizing a focus on non-surgical treatment options.

Additional Notes

This section includes any other relevant information, such as patient education on the importance of physiotherapy adherence and instructions for post-operative care. Documentation of informed consent, following a discussion of treatment risks and alternatives, is also vital for legal and ethical reasons.

Enhancing Documentation with Notis AI Medical Scribe

In the demanding field of orthopaedics, efficient documentation is crucial. AI medical scribes like Notis provide a solution by automating the creation of structured SOAP notes, significantly reducing the time spent on administrative tasks.

Key Benefits of Notis for Orthopaedic Surgeons

Notis leverages voice-to-text technology to capture patient interactions accurately, supporting orthopaedic surgeons by generating detailed medical notes. This allows clinicians to save up to 2 hours daily, which can be redirected towards patient care. The seamless integration with WhatsApp eliminates the need for additional software, ensuring ease of use and a familiar interface.

With a transcription accuracy of 99%, Notis ensures that medical notes are precise and reliable. The platform's multilingual support caters to diverse patient populations, enhancing communication and care quality. Furthermore, Notis offers efficient data management, allowing for easy retrieval and updating of patient records.

By incorporating Notis into their workflow, orthopaedic surgeons can enhance productivity, reduce burnout, and focus more on delivering high-quality care. This AI medical scribe serves as a valuable tool in modern healthcare, supporting the intricate documentation needs of orthopaedic specialists.

In conclusion, mastering the art of clinical documentation through structured templates and leveraging AI technology like Notis can significantly improve patient care and operational efficiency in orthopaedic practices.