ORTHOPEDIC SOAP NOTE SAMPLE 1
SUBJECTIVE: The patient is seen in followup for his left knee and left hip. He has had a left hip femoral neck fracture. He has had progressive osteoarthritic changes. He is having primarily pain in his left hip. It is diffuse pain over the lateral aspect of buttock and groin. His knee has rather diffuse pain as well. No mechanical symptoms there. We had done a knee scope on him several years ago.
OBJECTIVE: His exam today shows him walking without any ambulatory aid. He has got a cane at home, but he is reticent to use it. He has significantly diminished hip motion, in rotation especially, compared to the right. He can flex up to about 100 degrees. He can get full extension. His knee has really no effusion. He has got no joint line pain today. Zero to 130 of motion. Really no flexion pain. Collaterals are intact. He is neurovascularly intact distally.
X-rays obtained today of the hip and the knee show significant CPPD in the knee, really unchanged. His hip films show complete loss of superior joint space. The hardware is unchanged in position. No evidence of any loosening.
ASSESSMENT AND PLAN: Left hip osteoarthritis. We think the hip is likely the source of the knee as well given his exam today. We had a long discussion with the patient and his wife about this. He has had a previous corticosteroid injection in the hip, which helped. We talked about treatment options. We recommended total hip arthroplasty to him. We are going to have him see Dr. John Doe. He is very concerned about possibility of that surgery. We answered all their questions as best as we could.
ORTHOPEDIC SOAP NOTE SAMPLE 2
DIAGNOSIS: Status post Akin osteotomy and distal interphalangeal arthroplasty, left second and third toe.
SUBJECTIVE: The patient is doing very well at this time. She has very little pain or discomfort. The overall alignment remains excellent; this is both radiographically and clinically.
PLAN: She will continue to use the toe spacers for another month. Follow up with us in four weeks with repeat x-rays of the left foot and, hopefully, we can release her to other suitable activities at that time if all looks well.
ORTHOPEDIC SOAP NOTE SAMPLE 3
SUBJECTIVE: The patient and his wife return today. He has had a total knee replacement done on MM/DD/YYYY. He is doing fairly well. He is in rehabilitation. His range of motion with a CPM is from 0 to about 68. He is having some swelling, but he is improving. There is no significant calf tenderness. The patient was seen and examined. He has TED stockings. The incision is clean and dry. Staples are removed. Steri-Strips are placed.
ASSESSMENT AND PLAN:
1. The patient will get antibiotic sent to his home pharmacy.
2. He will return in two to four weeks’ time for re-examination. He will call the office in the interim if he has any change in symptoms or any questions.
3. He will stop his Coumadin and take Ecotrin b.i.d.
SUBJECTIVE: The patient is doing well. He is about three months status post arthroscopies, partial synovectomy, and medial meniscectomy. He still has some mild swelling, though he is making progress. His range of motion is significantly improved. He still has some low quad weakness, and this is improving with time.
PLAN: We decided to continue with his home exercise program. We will give him a GenuTrain knee brace, and he will return to see us in two months for repeat examination. Potentially, if he still has some achiness, may consider postoperative cortisone injection.
ORTHOPEDIC SOAP NOTE SAMPLE 5
SUBJECTIVE: The patient is a (XX)-year-old gentleman, following motor vehicle accident, with abrasions over the right knee and foot. We have been treating him for these abrasions. With pain, he saw (XX) about a week ago for completion of suture removal on his right foot wound. He has been putting some Silvadene on it.
OBJECTIVE: On examination, the wound is clean, dry, and intact. Dorsiflexion and plantar flexion is full without difficulty. He was able to wear a sneaker yesterday. He is still wearing the walker boot. The knee wound is clean and dry. There is some scabbing over the kneecap. There is no extensive erythema or signs of infection.
ASSESSMENT AND PLAN: He did have a bout of diarrhea and was seen by the PCP. This seems to be resolving. He seems to be doing quite well. The wound is healing nicely. We will continue with wet-to-dry dressing with Silvadene for the distal wound, and we will see him back in two weeks’ time to make sure he is continuing in the right direction.
ORTHOPEDIC SOAP NOTE SAMPLE 6
SUBJECTIVE: The patient returns to go over his left Achilles tendon and tendinitis. He has also now developed a right plantar fasciitis that he feels that he got from squatting activities. He found the night splint to be intolerable. He has tried various orthotics, which do not fit into the dress shoes that he wears, and he is interested in what sort of steps could be followed.
OBJECTIVE: He has fusiform swelling but no significant pain in his left Achilles tendon proximal to its insertion. On the right side, he has medial calcaneal origin tenderness consistent with plantar fasciitis.
ASSESSMENT AND PLAN: The patient has bilateral Achilles contracture with left Achilles tendinitis and right plantar fasciitis. We are going to send him to physical therapy to get him onto a stretching program, as he has been unsuccessful doing it on his own with a home program. We have gone over usual modalities, recommended arch supports and heel lifts, as well as night splints. He is going try to incorporate these into his daily activities, and we will see him back in six to eight weeks’ time.
