Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: Document any current complaints related to the hip fracture or surgery (pain, mobility limitations).
History of Present Illness:
Date of fall and mechanism of injury (if known)
Type of hip fracture (femoral neck, intertrochanteric, subtrochanteric)
Surgical procedure performed (internal fixation, arthroplasty)
Date of surgery (if applicable)
Postoperative course (mobility progress, pain control, complications)
Past Medical History:
Comorbid conditions (osteoporosis, diabetes, cardiovascular disease)
Previous fractures or surgeries
Medications (anticoagulants, steroids)
Functional status prior to fracture (independent ambulation, use of assistive devices)
Cognitive status (potential impact on rehabilitation)
Social History:
Living situation (home alone, assisted living)
Social support system (availability of caregiver)
Physical Examination:
Vital signs (check for fever, infection)
General appearance (pain, discomfort)
Neurologic exam (motor and sensory function in the affected leg)
Wound assessment (dressing changes, drainage, signs of infection)
Range of motion of the hip joint
Assessment of strength and gait (with or without assistive device)
Laboratory Tests:
Complete blood count (CBC) – to monitor for infection
Electrolytes – to assess hydration and potential complications
Imaging Studies:
X-ray (to assess fracture healing) – may be repeated during follow-up visits
Diagnosis:
Hip fracture (specify type)
Postoperative status (e.g., following ORIF for intertrochanteric fracture)
Treatment Plan:
Pain management (medications, physical therapy)
Physical therapy (gait training, strengthening exercises)
Occupational therapy (activities of daily living training)
Weight-bearing status (restricted weight bearing, full weight bearing as tolerated)
Thromboprophylaxis (blood clot prevention)
Discharge planning (home care, rehabilitation facility)
Prognosis:
Discuss expected recovery timeline and potential complications (e.g., pneumonia, blood clots)
Importance of rehabilitation for regaining mobility and function
Patient Education:
Importance of following weight-bearing instructions
Pain management strategies
Importance of physical and occupational therapy exercises
Fall prevention measures
Warning signs of infection (fever, redness, increased pain)
Next Follow-up:
Schedule for the next appointment to monitor progress, adjust treatment plan, and address any concerns.