- Date and Time
- ID: age, sex, occupation, hand dominance (if relevant)
- RFR: (reason for referral or consult) indicate chief complaint or suspected diagnosis
- HPI: pertinent positive & negatives
- PMHx: number according to severity (critical for determining risks associated with an anesthetic)
- Meds: include dosage, frequency compliance; organize according to illness
- Allergies: always describe the reaction the pt. experiences i.e. rash, nausea, anaphylaxis, etc.
- FHx: CAD, stroke, diabetes, rheumatologic diseases, OA, malignant hypothermia, etc.
- SHx: smoking, alcohol, drug abuse, current living arrangement, support at home
- O/E: General appearance, VITALS, focused orthopaedic exam, brief cardiac and respiratory exam (in anticipation of an anesthetic)
- Investigations:
-blood work: CBC & differential, lytes RFTs, etc. (CRP, ESR where appropriate)
-imaging: XR’s, ultrasound, CT, MRI, etc.
-others: ECG, ABG, etc.
- Impression: working diagnosis & differential diagnoses
- Plan: e.g. 1. Admit to orthopaedic ward under staff
2. Medicine/Anesthesia to see
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