Orthopaedics Assessment Report

---
name: orthopaedics-assessment-report
description: |
  Assess patients with bone, joint and muscle injuries or conditions and write a defensible findings report as a orthopaedic surgeon.
  TRIGGERS - Use when a orthopaedic surgeon needs a assessment & findings report for patients with bone, joint and muscle injuries or conditions in an orthopaedic theatre and fracture clinic.
category: Orthopaedics
license: MIT
version: 1.0
---
# Assessment & Findings Report — Orthopaedics

Assess patients with bone, joint and muscle injuries or conditions and write a defensible findings report as a orthopaedic surgeon. The deliverable is a structured assessment report with findings, evidence and recommendations.
This skill is written for a orthopaedic surgeon working with patients with bone, joint and muscle injuries or conditions in an orthopaedic theatre and fracture clinic.

## When to use
- You are a orthopaedic surgeon preparing, delivering or reviewing this part of your work in an orthopaedic theatre and fracture clinic.
- You need a defensible, repeatable approach that produces a structured assessment report with findings, evidence and recommendations.
- A colleague, auditor or client asks how this was done and what evidence supports it.

## Key Concepts
| Term | Meaning |
|------|---------|
| Fracture | a break in a bone |
| Arthroplasty | surgical replacement of a joint |
| Compartment syndrome | dangerous pressure build-up within a muscle compartment |

## Workflow
1. **Step 1** - Review the intake record and operation notes so the assessment builds on verified information, not assumptions
2. **Step 2** - Carry out the assessment using operating microscopes and drills, following the recognised method for an orthopaedic theatre and fracture clinic
3. **Step 3** - Compare findings against the benchmarks behind surgical site infection rate and note where evidence is strong, weak or missing
4. **Step 4** - Draft the report: findings first, then interpretation, then recommendations in priority order
5. **Step 5** - Check the draft for accuracy and for wrong-site surgery; have it reviewed where the profession's standards require a second sign-off

## Profession-Specific Components
| Component | Details for Orthopaedics |
|-----------|-------------------------------|
| Core documentation | operation notes; fracture assessments; implant records; physiotherapy referrals |
| Core tools & equipment | operating microscopes and drills; C-arm fluoroscopy; splints and casts; traction equipment |
| People involved | patients with bone, joint and muscle injuries or conditions; the orthopaedic surgeon; colleagues and other services in an orthopaedic theatre and fracture clinic |
| Primary record | operation notes — keep it current, dated and attributable |

## Output Format
**Context:** [Situation in an orthopaedic theatre and fracture clinic] | **Objective:** [What this must achieve] | **Audience:** [patients with bone, joint and muscle injuries or conditions and other stakeholders]

The finished output is a structured assessment report with findings, evidence and recommendations, structured as:
1. Summary of position and evidence
2. Detail, following the workflow above
3. Decisions, actions, owners and dates
4. Review point and escalation route

### Action Plan
1. **Immediate:** Confirm scope, consent and the evidence available in operation notes.
2. **Short-term:** Complete the workflow steps and record outcomes against surgical site infection rate.
3. **Medium-term:** Review results, close actions, and update local procedures in an orthopaedic theatre and fracture clinic.

## Success Metrics
| Metric | Target | Method |
|--------|--------|--------|
| surgical site infection rate | Agree a local target and track the trend | Measured from operation notes and reviewed on a set cycle |
| fracture clinic waiting time | Agree a local target and track the trend | Measured from operation notes and reviewed on a set cycle |
| implant revision rate | Agree a local target and track the trend | Measured from operation notes and reviewed on a set cycle |
| mobility recovery scores | Agree a local target and track the trend | Measured from operation notes and reviewed on a set cycle |

## Guardrails & Quality Checks
- Never let this happen: wrong-site surgery.
- Never let this happen: compartment syndrome missed.
- Never let this happen: post-operative infection.
- Work only within the competence and authority of a orthopaedic surgeon; escalate or refer anything beyond it.
- Record facts and observations, not speculation, and keep records confidential to an orthopaedic theatre and fracture clinic's rules.
- Verify names, dates, figures and measurements twice before anything is issued or signed off.
- Use only real, verified information from the case in hand — never invent results, credentials or evidence.

## Example (illustrative)
A orthopaedic surgeon in an orthopaedic theatre and fracture clinic applies this workflow for patients with bone, joint and muscle injuries or conditions: they open
operation notes, work through the five steps using operating microscopes and drills, and close by recording
the outcome against surgical site infection rate and agreeing the next review date. (Illustrative example only —
replace with the real details of the case in hand.)