New Patient Evaluation (Orthopedic Surgery)

Last updated: Nov 2025

Orthopedic Surgery — New Patient Evaluation that’s HIPAA-compliant: capture the encounter or upload audio, generate a structured MSK note (hip/knee/shoulder/spine/hand), then auto-fill your EHR via the Nudge Chrome extension (edit-before-save).

Who this helps

• Orthopedic surgeons & sports-medicine physicians

• APPs (PAs/NPs) in high-volume clinics and inpatient consults

• Multi-site groups standardizing MSK documentation
  
  

What you get

• Structured Chief Complaint, HPI, Prior Treatments (PT/injections/bracing), MSK Exam, Neurovascular status, Imaging/Studies, Assessment, Plan

• Optional: PROs (KOOS/HOOS/QuickDASH), work/activity restrictions, surgical candidacy criteria

• 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 and tailor MSK exam terms and laterality.

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

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

How to write an Ortho New-Patient note

• Chief Complaint & HPI: mechanism, onset, location, quality, severity, mechanical/instability symptoms, prior care.

• MSK Exam: inspection, ROM, strength, special tests, neurovascular status, gait; document laterality.

• Imaging/Studies: X-ray/MRI/CT reviewed or ordered; note measurements if applicable.

• Assessment: working diagnosis + key differentials; operative vs non-operative path.

• Plan: imaging orders, analgesia, PT/protocols, bracing/injections, meds, work/activity restrictions, follow-up; pre-op if surgical pathway.
  
  

Quick examples

• Hip fracture suspicion: shortened, externally rotated leg; urgent hip films; admit, analgesia, DVT ppx; OR planning.

• Meniscal tear: joint-line tenderness, +McMurray; MRI vs conservative care; activity modification; PT.

• Shoulder impingement: painful arc, +Hawkins/Neer; subacromial injection + PT; f/u 4–6 weeks.
  
  

Full Sample Note — New Patient Evaluation (Orthopedic Surgery)

Example only; not medical advice.

ORTHOPEDICS NEW PATIENT ASSESSMENT

Chief Complaint: Left hip pain after fall

HPI / SUBJECTIVE:
Margaret is a 79-year-old woman who fell at home this morning after catching her toe on a rug. She landed on the left side and could not stand afterward. Pain is severe, constant, and worsens with any movement; 8/10 at rest, 10/10 with motion. No chest pain, presyncope, or syncope before the fall. No head strike or loss of consciousness. Baseline mobility: cane indoors, walker outdoors; lives alone in a one-story home. She's had several near-falls in the last year. Denies fever, cough, urinary symptoms, or recent illness.

PMH: Hypertension; Osteoporosis; Hyperlipidemia
PSH: None

MEDICATIONS:

• Lisinopril 10 mg daily

• Atorvastatin 20 mg nightly

• Alendronate 70 mg weekly

• Calcium/Vit D

ALLERGIES: NKDA

FH: Mother—osteoporosis; Father—MI in his 80s

SH: Widowed; retired librarian; former smoker (quit 30 yrs); occasional wine

REVIEW OF SYSTEMS:
General: No fever/chills, no unintentional weight loss.
Cardiac: No chest pain, palpitations, edema.
Pulmonary: No dyspnea, cough, wheeze.
GI: No N/V/D; no melena/hematochezia.
GU: No dysuria/hematuria.
Neuro: No focal weakness/numbness prior to fall.
MSK: Severe left hip pain; no other joint complaints.
Skin: No wounds aside from bruising over hip.

PHYSICAL EXAM:
Vitals: BP 138/76, HR 74, RR 16, SpO₂ 98% RA, afebrile.
General: Uncomfortable, supine, cooperative.
Cardiac: RRR, no murmurs; distal pulses 2+.
Pulmonary: Clear to auscultation bilaterally; normal effort.
Abdomen: Soft, NT/ND.
MSK: Left leg shortened and externally rotated; exquisite tenderness over proximal femur; pain with any passive motion; cannot bear weight.
Neurovascular (LE): Sensation intact to light touch; dorsalis pedis and posterior tibial pulses palpable; foot warm with brisk cap refill.
Skin: Ecchymosis lateral hip; no skin breaks.

ASSESSMENT & PLAN:
79F with mechanical fall and exam highly suggestive of displaced left femoral neck fracture on a background of osteoporosis. She is functionally limited and in significant pain; operative fixation is indicated to restore mobility and reduce morbidity.

1. LEFT FEMORAL NECK FRACTURE (SUSPECTED/DISPLACED)
   • Orders: AP pelvis + dedicated hip films now; CT pelvis if fracture pattern unclear for surgical planning.
   • Admit to orthopedics; NPO after midnight; IV fluids; multimodal analgesia (acetaminophen scheduled, low-dose opioid PRN; bowel regimen).
   • Pre-op: hospitalist/anesthesia evaluation; type & screen; DVT prophylaxis per protocol.
   • Plan: Anticipate OR tomorrow pending clearance; risks/benefits discussed with patient and daughter; they agree with plan.

2. HYPERTENSION
   • Well controlled. Continue lisinopril unless anesthesia advises hold morning of surgery; monitor perioperatively.

3. OSTEOPOROSIS
   • Likely contributor. Continue calcium/Vit D. Alendronate to resume post-op when safe; coordinate long-term management with PCP; reinforce fall-prevention (home safety, assistive devices).

4. HYPERLIPIDEMIA
   • Continue atorvastatin.

Follow up: Inpatient ortho rounds daily; outpatient clinic wound check at 2 weeks post-op, sooner for fever, wound drainage, or uncontrolled pain.

Results (2025)

Typical ortho new-patient note ready in < 60–90 seconds after capture.
Teams report 4–6 hrs/week saved and more consistent exam phrasing across providers.

FAQs

Can we standardize hip/knee exam phrasing (e.g., ROM format, special-test wording)?
Yes. Save preferred phrasing and set required fields (laterality, neurovascular, gait) before export.

Does it support peri-op workflows?
Yes. Add pre-op clearance items, consent, implants, and post-op protocols to the plan; map to your EHR.

How do you handle multi-region or polytrauma?
Use multi-complaint mode: separate HPI + exam blocks per region with a single integrated plan.