Orthopaedics Intake Assessment

---
name: orthopaedics-intake-assessment
description: |
  Run a structured intake and initial assessment for patients with bone, joint and muscle injuries or conditions in an orthopaedic theatre and fracture clinic.
  TRIGGERS - Use when a orthopaedic surgeon needs a intake & initial assessment for patients with bone, joint and muscle injuries or conditions in an orthopaedic theatre and fracture clinic.
category: Orthopaedics
license: MIT
version: 1.0
---
# Intake & Initial Assessment — Orthopaedics

Run a structured intake and initial assessment for patients with bone, joint and muscle injuries or conditions in an orthopaedic theatre and fracture clinic. The deliverable is a completed intake record and initial assessment summary.
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 completed intake record and initial assessment summary.
- 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** - Confirm identity, consent and the reason for referral or engagement, and open the record that will hold operation notes
2. **Step 2** - Gather history and current circumstances from patients with bone, joint and muscle injuries or conditions, using the standard intake structure for an orthopaedic theatre and fracture clinic
3. **Step 3** - Record baseline observations and measurements relevant to surgical site infection rate, noting anything that changes the priority of the case
4. **Step 4** - Flag immediate concerns — especially wrong-site surgery — and escalate or fast-track anything urgent before proceeding
5. **Step 5** - Summarise findings for patients with bone, joint and muscle injuries or conditions in plain language, agree the next step, and file the intake section of operation notes

## 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 completed intake record and initial assessment summary, 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.)