Ortho note...please advise!

[double elle]

Hi all - MS4 here doing a month of ortho...
How do you write an ortho note? I don't know what to include! Most of our patients have med management docs who monitor the urine, lungs, CV, etc...

Does my ortho guy want to see LCTAB, HRRR, etc...??

Does the ortho guys want to know if the patient has had a BM?

I check movement of distal joints (wiggling toes after a total hip, for example) and I ask about pain control. When they start to ambulate, I ask how that is going...but I feel this is such a small progress note compared to the other ones I'm used to writing for medicine and such. He doesn't want me checking the incisions until several day post op, so I don't need to do that. His notes are about 4-5 lines long...VERY abbreviated and short...but I don't know - as a student - what MY notes should be like.

I just want to know I'm covering all my bases!

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[doc05]

no surgeon wants to read a medicine note.

ps. you're very close to graduation...perhaps you should use your own judgment.

 

[ortho2003]

Hi all - MS4 here doing a month of ortho...
How do you write an ortho note? I don't know what to include! Most of our patients have med management docs who monitor the urine, lungs, CV, etc...

Does my ortho guy want to see LCTAB, HRRR, etc...??

Does the ortho guys want to know if the patient has had a BM?

I check movement of distal joints (wiggling toes after a total hip, for example) and I ask about pain control. When they start to ambulate, I ask how that is going...but I feel this is such a small progress note compared to the other ones I'm used to writing for medicine and such. He doesn't want me checking the incisions until several day post op, so I don't need to do that. His notes are about 4-5 lines long...VERY abbreviated and short...but I don't know - as a student - what MY notes should be like.

I just want to know I'm covering all my bases!

my notes cover the following. Rarely do I have more than these seven lines, unless it is complex trauma patient, or a spinal cord injury.

subjective
vitals, Hgb, PT/INR/PTT
DSG/Incision?drain output
neurovasc status
A/P
what they had done and post op day
PT/OT weight bearing status
ABX/DVT proph
Disposition

 

[double elle]

thanks Ortho2003 -
I pretty much cover all that...but I just wondered if I needed to cover the additional stuff I mentioned...bm, lungs, CV, whether he's eating or not..etc..

That helps...thanks again.

 

[SOUNDMAN]

my notes are very simple:

S: Doing well, walked so far. any c/o's?

O: Afebrile, VSS, Hgb
I/O w/ drain etc
Dressing C/D/I (Clean/Dry/Intact)
Distal NV function (neurovas)
CVT - calf vein tenderness yes or no

A/P: S/P whatever
PT/OT
any med changes

Usually have a medicine guy following.