Follow-Up (Orthopedic Surgery)

Last updated: Nov 2025

Orthopedic Follow-Up that’s HIPAA-compliant: capture the visit or upload audio, generate a structured note (interval history → exam → imaging → plan), then auto-fill your EHR via the Nudge Chrome extension (edit-before-save).

Who this helps

• Orthopedic surgeons & sports-medicine physicians

• APPs (PAs/NPs) running high-throughput clinics

• Multi-site teams standardizing post-op and non-op follow-ups
  
  

What you get

• Structured Chief Complaint/Reason, Interval History, Pain & Function, MSK Exam, Imaging/Studies, Assessment, Plan, Work/Activity Restrictions, Follow-Up

• Optional PROs (e.g., ASES/QuickDASH/HOOS/KOOS), PT milestones, return-to-work/sport tracking

• Team-wide formatting controls (bullets/paragraphs) + redaction; carry-forward across visits
  
  

How it works with your EHR

1. Capture or upload in Nudge → draft appears.

2. Review & finalize exam phrasing (ROM format, strength scale, laterality).

3. In your EHR, open a new note and launch Nudge.

4. Select patient + note type → confirm mapping (Interval History, MSK Exam, Imaging, Assessment, Plan) → save & sign.
   No IT project required.
   
   

How to write an Ortho Follow-Up note

• Chief Complaint / Reason: post-op or non-op follow-up + timing (e.g., “6 weeks s/p RCR”).

• Interval History: pain today (0–10), function since last visit, PT adherence, complications red flags.

• Pain & Function: daily tasks, work/sport status, optional PROs.

• MSK Exam: incision status, ROM (active/passive), strength (out of 5), special tests as relevant, gait, neurovascular.

• Imaging / Studies: what was reviewed/ordered; key findings.

• Assessment: response to treatment; phase of rehab; any concerns.

• Plan: PT phase/milestones, meds or injections, restrictions, next interval; criteria to advance.

• Work / Activity Restrictions: specific loads/motions/time frames.

• Follow-Up: exact interval + triggers for sooner return.
  
  

Quick examples

• Knee arthroscopy 2 weeks: incision WNL; ROM goals; quad activation; DVT/wound red flags; f/u 4 weeks.

• Non-op shoulder impingement: improved pain with PT; add rotator cuff/scapular strengthening; avoid provocative motions; f/u 6 weeks.
  
  

Full Sample Note — Follow-Up (Orthopedic Surgery)

Example only; not medical advice.

Patient: [Name], 61F
Chief Complaint: 6-week follow-up after right rotator cuff repair

HPI / SUBJECTIVE:

Patient is now 6 weeks post right rotator cuff repair. She reports continued improvement with pain rated 1–2/10, significantly better than preoperatively. Sleeping more comfortably without nocturnal awakening. She completed the prescribed sling protocol and has been compliant with physical therapy. Denies wound issues, drainage, erythema, fever, or chills. Functionally, she is still cautious with overhead activities but denies catching, locking, or mechanical symptoms. No neurologic complaints.

OBJECTIVE:
PHYSICAL EXAM:

• Incision: Well-healed, no erythema, drainage, or keloid formation.

• Shoulder (Right): Passive forward flexion 140°, abduction 120°. Active scaption to 100° without hiking. External rotation at side 30°. Rotator cuff strength improving at 4/5 with mild pain inhibition. No crepitus.

• Neurovascular: Intact distally.

DIAGNOSTICS:

• No new imaging obtained today; clinical course and exam are reassuring.

• PT reports reviewed in EHR confirming appropriate progression.

ASSESSMENT & PLAN:

This is a 61-year-old woman 6 weeks post right rotator cuff repair who is demonstrating appropriate healing trajectory. Exam shows satisfactory passive and early active ROM with no complications at the incision site. Rotator cuff strength is returning as expected.

1. Post-Operative Rotator Cuff Repair (Right Shoulder, 6 Weeks)

• Continue physical therapy: advance to active ROM and begin light isometric strengthening this week.

• Activity restrictions: no lifting >5–8 lb; avoid sudden abduction/external rotation.

• At 10–12 weeks: if ROM milestones achieved, transition to progressive strengthening phase.

• Education: reviewed expected recovery course and realistic timeline for return to sport or heavy work (generally 4–6 months). Discussed importance of avoiding premature overhead loading to reduce re-tear risk.

2. Hypertension

• Remains stable on amlodipine. Continue current regimen.

• Monitor BP at home; follow with PCP for chronic management.

FOLLOW UP:
Return in 6 weeks to reassess ROM, strength progression, and readiness for more advanced activities. Call sooner for new weakness, recurrent night pain, wound changes, or mechanical catching.

DIAGNOSES:

• Z47.89 — Encounter for orthopedic aftercare following surgery

• M75.121 — Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic (post-repair)

• I10 — Essential (primary) hypertension
  
  

Results (2025)

Follow-up notes ready in < 60–90 seconds after capture.
Teams report 4–6 hrs/week saved and clearer rehab-phase handoffs to PT.

FAQs

Can we lock in ROM and strength formats (e.g., 0–180°, 0–5 scale)?
Yes. Save organization defaults and require laterality, ROM units, and strength scales before export.

Can we embed PT milestones and auto-advance rules?
Yes. Define phase gates (e.g., pain <3/10, ER ≥45°) and surface them in the Plan.

How do you handle return-to-work/sport letters?
Generate templated letters from the note with load limits, durations, and next review date.