ortho note

S - No blood, pus, hot
O - Pt. alive
A/P- Keep pt. alive (or relevant limb)

)

Here was my typically note as a resident and now as a staff, assuming a non-complex patient following surgery

No C/O's, adequate pain control
Tm 37.8, VSS, drain 30cc last shift, Hct 35
incision benign, CMS intact, drain pulled
Homan's negative
A/P; POD#2 s/p TKA
continue PT/CPM
DVT prophylaxis
etc...

Now on a trauma patient, you may want to have categories in your plan such as

Central line day #3
Abx: Ancef/Gent Day #3
Foley: Pull on day 3
Heme: Hct 23, transfuse today
DVT prophylaxis: fragmin, T/Vs
s/p ORIF BBFA Fx - continue splinting, check wound tommorrow
s/p R femoral rodding - up in chair today, begin PT tommorrow

etc...

it's easy to lose focus on a few of the details on a trauma patient, so if you keep a few things in these notes, you won't forget to get tasks done.

A couple tips that I learned from the residents regarding the PE part of the SOAP note. They just document the neurovascular exam distal to whatever was operated on. Example:

RLE: In Bledsoe brace, CPM
dsg c/d/i, dsg changed, incision benign
5/5 TA/EHL/GS
Sens intact to LT in sp/dp/t/s/s dist
2+DP/PT

I put this in for the first day or two post-op so that its clearly documented. After that (if they are still there), I just write the beloved: NVI distally

Obviously you'll have to tailor your PE to whatever surgery the patient had (ie: shoulder surgery--> axillary n is important). Ask your resident if you are unsure. Hope this helps and good luck.

I'm doing ortho trauma/joints right now, and the following are recorded by most residents:

Tmax
Drain output
Neurovascular status -- pulses, cap refill, distal sensation
Condition of wound (well-healed, C/D/I) and dressing
POD number, procedure performed
Weight bearing status for physical therapy
DVT prophylaxix
"Doing well"!!!

My advice now as an intern who has to see everyone on service before 6:30 conference is to keep it simple. just think what the reason is the person is in the hospital and relate to that. Of course if they have other concerns/complaints you must document (i.e., chest pain, afib, ect.) talk about wound, dressing (saturated, clean, dry, intact, pussed out) senstation distal and proximal to injury or incision, motor funtion distal and proximal to injury/incision and plan. If as a student you don't know the whole plan, ask. Typically you are going to have PT, DVT prophylaxis, dressing changes, pain control ect. you'll get the hang of it after about 2 days.

At the Mayo one of the ortho residents included this little box at the top right of his notes as a little reminder. It was labeled "A,B,C,D,E"

A for Abx
B for Blood work (cbc, coags, cultures, etc)
C for (for get was C was for - maybe cultures)
D for DVT prophylaxis
E for exercise (i.e. PT, OT)

I don't use it, but I thought it was a cool reminder of things to think about day to day.