Orthopedics: Step-by-Step Guide on How to Write SOAP Notes

Updated January 2026

Orthopedic documentation requires meticulous attention to musculoskeletal examination findings, imaging interpretation, and treatment planning. Whether managing acute fractures, chronic degenerative conditions, or complex surgical cases, orthopedic SOAP notes must capture detailed physical examination findings, imaging correlations, and clinical decision-making. This guide provides comprehensive instructions for documenting orthopedic encounters from initial evaluation through surgical planning and post-operative care.

Unique Aspects of Orthopedic Documentation

Orthopedic documentation differs from other medical specialties in several key ways:

1. Detailed Musculoskeletal Examination: Systematic evaluation including inspection, palpation, range of motion, strength testing, and joint-specific special tests
2. Imaging Interpretation: Integration of X-ray, MRI, CT, and other imaging findings with clinical presentation
3. Surgical Planning Documentation: Pre-operative evaluation, surgical indications, and procedure-specific planning
4. Mechanism of Injury: Detailed documentation of injury circumstances for trauma cases and medicolegal purposes
5. Functional Assessment: Objective measurement of patient function and disability level
6. Laterality Documentation: Critical accuracy in left vs. right documentation to prevent wrong-site surgery
7. DME and Rehabilitation Coordination: Bracing, orthotics, and physical therapy prescription documentation
8. Return-to-Work/Sports Assessment: Functional capacity evaluation and activity clearance documentation

Subjective Section (S)

The Subjective section in orthopedics captures the patient's description of their musculoskeletal complaint, mechanism of injury, functional limitations, and treatment history. This information is critical for diagnosis, treatment planning, and medicolegal documentation.

Subjective Section (S) Components

1. Chief Complaint:

   • Primary musculoskeletal symptom with duration
   • Specific anatomic location with laterality
   • Example: "Right knee pain and swelling for 3 weeks following a twisting injury"

2. Mechanism of Injury (MOI):

   • Detailed description of how injury occurred
   • Position of limb at time of injury
   • Forces involved (twisting, direct blow, fall)
   • High-energy vs. low-energy mechanism
   • Workplace or motor vehicle accident details if applicable
   • Example: "Patient was playing basketball when he landed awkwardly after a jump, felt a 'pop' in his right knee with immediate swelling. Non-contact injury with knee in valgus and external rotation."

3. Pain Characteristics:

   • Location (specific anatomic site, radiation pattern)
   • Quality (sharp, dull, aching, burning, throbbing)
   • Intensity (0-10 numeric rating scale)
   • Timing (constant, intermittent, with activity)
   • Aggravating factors (specific movements, weight-bearing, stairs)
   • Alleviating factors (rest, ice, elevation, medications)
   • Night pain (concerning for tumor, infection, or inflammatory condition)
   • Example: "Sharp pain localized to the medial joint line, rated 7/10, worse with pivoting and stairs, improved with rest and ice"

4. Functional Limitations:

   • Impact on activities of daily living (ADLs)
   • Ambulatory status (distance, assistive device use)
   • Work-related limitations
   • Sports and recreational impact
   • Sleep disturbance
   • Example: "Unable to walk more than one block, using crutches, cannot climb stairs without handrail, unable to work as construction laborer"

5. Mechanical Symptoms:

   • Locking or catching
   • Giving way or instability
   • Clicking, popping, or grinding
   • Stiffness (morning vs. activity-related)
   • Swelling pattern (immediate vs. delayed, recurrent)
   • Example: "Reports knee 'gives out' with pivoting, intermittent catching sensation, immediate swelling after the injury that has persisted"

6. Prior Treatments:

   • Previous conservative measures (RICE, bracing, PT)
   • Medications tried (NSAIDs, analgesics, topical agents)
   • Previous injections (corticosteroid, viscosupplementation, PRP)
   • Prior surgeries on affected or contralateral joint
   • Response to previous treatments
   • Example: "Tried 2 weeks of physical therapy with minimal improvement. Ibuprofen 600mg TID provides partial relief. Previous ACL reconstruction on left knee in 2018."

7. Red Flag Symptoms:

   • Constitutional symptoms (fever, weight loss, fatigue)
   • Night pain not relieved by position change
   • Progressive neurological symptoms
   • Bowel or bladder dysfunction (for spine)
   • History of malignancy
   • Example: "Denies fever, night sweats, or unexplained weight loss. No bowel or bladder dysfunction."

8. Relevant Medical History:

   • Previous orthopedic conditions and surgeries
   • Rheumatologic conditions
   • Osteoporosis or metabolic bone disease
   • Diabetes (affects healing)
   • Vascular disease (affects surgical planning)
   • Smoking status (critical for bone healing and fusion)
   • Anticoagulation status
   • Example: "History of type 2 diabetes (HbA1c 7.2%), former smoker quit 5 years ago, no prior knee surgeries"

9. Occupational and Activity History:

   • Occupation and job demands
   • Dominant hand (for upper extremity)
   • Athletic activities and level of competition
   • Recreational activities
   • Example: "Works as an electrician requiring kneeling and ladder climbing. Recreational basketball player."

Example Subjective Section for Orthopedics

Objective Section (O)

The Objective section in orthopedics requires a systematic musculoskeletal examination with detailed documentation of inspection, palpation, range of motion, strength, special tests, and neurovascular status. Accurate documentation supports diagnosis, surgical planning, and coding requirements.

Objective Section (O) Components

1. Vital Signs:

   • Blood pressure, heart rate, temperature (especially for infection workup)
   • Height, weight, BMI (relevant for joint replacement planning)
   • Example: "BP 128/78, HR 72, Temp 98.4F, Height 5'10", Weight 195 lbs, BMI 28.0"

2. General Appearance:

   • Ambulatory status and gait pattern
   • Use of assistive devices
   • Overall body habitus
   • Example: "Ambulates with crutches, antalgic gait favoring right lower extremity"

3. Inspection:

   • Alignment and deformity
   • Swelling and effusion
   • Ecchymosis and skin changes
   • Muscle atrophy
   • Surgical scars
   • Symmetry compared to contralateral side
   • Example: "Moderate effusion of right knee, no ecchymosis, no gross malalignment, no obvious muscle atrophy compared to left"

4. Palpation:

   • Point tenderness (specific anatomic location)
   • Effusion assessment (ballottement, fluid wave)
   • Warmth or coolness
   • Crepitus
   • Soft tissue masses
   • Bony landmarks
   • Example: "Tenderness to palpation along medial joint line and over medial femoral condyle. Positive ballottement indicating moderate effusion. No warmth. No crepitus."

5. Range of Motion (ROM):

   • Active and passive ROM
   • Comparison to contralateral side or normal values
   • Quality of motion (smooth vs. painful arc, crepitus)
   • Document in degrees using goniometer measurements when possible
   • Example: "Right knee ROM: Flexion 0-125 degrees (limited by pain and swelling), Extension 0 degrees (full). Left knee: 0-140 degrees. Pain at end-range flexion."

6. Strength Testing:

   • Manual muscle testing using 0-5 scale
   • Compare to contralateral side
   • Note pain-limited vs. true weakness
   • Example: "Quadriceps strength 4/5 on right (pain-limited), 5/5 on left. Hamstring strength 5/5 bilaterally."

7. Special Tests (Joint-Specific): Document each test performed with specific findings:

   Knee-Specific Tests:

   • Lachman test (ACL)
   • Anterior/posterior drawer (ACL/PCL)
   • Pivot shift (ACL)
   • Valgus/varus stress (MCL/LCL)
   • McMurray test (meniscus)
   • Thessaly test (meniscus)
   • Patellar grind/compression (patellofemoral)
   • Patellar apprehension (instability)

   Shoulder-Specific Tests:

   • Neer impingement sign
   • Hawkins-Kennedy test
   • Empty can/Jobe test (supraspinatus)
   • Lift-off/Gerber test (subscapularis)
   • Hornblower sign (teres minor)
   • Speed test/Yergason test (biceps)
   • O'Brien test (labrum/AC joint)
   • Apprehension/relocation (instability)
   • Cross-body adduction (AC joint)

   Spine-Specific Tests:

   • Straight leg raise (SLR)
   • Crossed SLR
   • Femoral nerve stretch
   • Spurling test (cervical)
   • Hoffmann sign
   • Babinski sign

8. Neurovascular Examination:

   • Sensation (dermatomal distribution)
   • Motor function (myotomal distribution)
   • Reflexes (deep tendon reflexes)
   • Pulses (dorsalis pedis, posterior tibial for lower extremity)
   • Capillary refill
   • Example: "Sensation intact to light touch in L3-S1 distributions. Motor: EHL 5/5, tibialis anterior 5/5. Reflexes: Patellar 2+, Achilles 2+ bilaterally. DP and PT pulses 2+ bilaterally. Cap refill under 2 seconds."

9. Gait Analysis:

   • Gait pattern (normal, antalgic, Trendelenburg, steppage)
   • Assistive device use
   • Stance and swing phase observations
   • Example: "Antalgic gait with shortened stance phase on right. Using bilateral crutches with partial weight-bearing."

10. Imaging Interpretation: Document imaging reviewed with specific findings:

    X-Ray Findings:

    • Views obtained
    • Alignment and joint space
    • Bone quality
    • Fracture description (if present): location, pattern, displacement, angulation
    • Soft tissue findings

    MRI Findings:

    • Sequences reviewed
    • Soft tissue pathology
    • Cartilage status
    • Bone marrow edema
    • Ligament and tendon integrity

    CT Findings:

    • Fracture characterization
    • 3D reconstruction findings
    • Hardware position (if applicable)

Joint-Specific Examination Templates

Example Objective Section for Orthopedics

Assessment Section (A)

The Assessment section synthesizes clinical findings, imaging results, and clinical reasoning to formulate diagnoses and determine the appropriate treatment pathway, including surgical versus conservative management decisions.

Assessment Section (A) Components

1. Primary Diagnosis:

   • Specific diagnosis with ICD-10 code
   • Laterality
   • Acuity (acute, chronic, acute-on-chronic)
   • Example: "Complete ACL tear, right knee (S83.511A)"

2. Secondary Diagnoses:

   • Associated injuries or conditions
   • Contributing factors
   • Example: "Medial meniscus posterior horn tear, right knee (S83.211A)"

3. Clinical Reasoning:

   • Correlation of history, exam, and imaging
   • Differential diagnosis consideration
   • Why conservative vs. operative management recommended
   • Example: "Clinical examination consistent with ACL insufficiency (positive Lachman with soft endpoint, positive pivot shift), corroborated by MRI findings of complete ACL tear. Associated medial meniscus tear explains mechanical symptoms."

4. Surgical Candidacy Assessment:

   • Activity level and goals
   • Age and bone quality
   • Comorbidities affecting surgical risk
   • Prior surgical history
   • Compliance/rehabilitation potential
   • Example: "Patient is an appropriate surgical candidate given young age (32), active lifestyle with desire to return to basketball, good overall health, history of successful ACL reconstruction on contralateral side, and high motivation."

5. Conservative Treatment Candidacy:

   • When conservative care is appropriate
   • Expected outcomes with non-operative treatment
   • Criteria for conversion to surgery
   • Example: "For low-demand patients, non-operative management with activity modification and PT could be considered, however this patient's activity goals and recurrent instability episodes indicate surgical reconstruction is preferred."

6. Risk Stratification:

   • Surgical risks (infection, DVT, stiffness)
   • Anesthetic considerations
   • Diabetes and wound healing
   • Smoking status
   • Example: "Surgical risks include infection (elevated risk with diabetes, though HbA1c is well-controlled), DVT (will use chemoprophylaxis), and stiffness. Non-smoker status and prior successful surgery are favorable prognostic factors."

7. Prognosis:

   • Expected functional outcome
   • Return to work/sport timeline
   • Re-injury risk
   • Example: "With ACL reconstruction and meniscus repair, good to excellent outcome expected. Return to full activities including basketball anticipated at 9-12 months post-operatively. Re-tear risk approximately 5-10%."

Example Assessment Section for Orthopedics

Plan Section (P)

The Plan section outlines the complete treatment approach including conservative management, surgical planning, rehabilitation, and follow-up care.

Plan Section (P) Components

1. Conservative Management:

   • Activity modification
   • Bracing and immobilization
   • Physical therapy prescription
   • Medications (NSAIDs, analgesics)
   • Ice/heat protocols
   • Example: "Hinged knee brace locked in extension for ambulation. Physical therapy 2x/week for ROM, quadriceps strengthening, and gait training. Ibuprofen 600mg TID with food PRN for pain."

2. Surgical Planning (if indicated):

   • Planned procedure with laterality
   • Surgical approach and technique
   • Graft selection (for ligament reconstruction)
   • Anesthesia plan
   • Position and equipment needs
   • Timeline for surgery
   • Example: "Plan for right knee arthroscopy with ACL reconstruction using BTB autograft, with meniscus repair if tear is amenable"

3. Pre-operative Optimization:

   • Prehabilitation physical therapy
   • Medical clearance requirements
   • HbA1c optimization for diabetics
   • Smoking cessation
   • Medication adjustments (anticoagulation, diabetes)
   • Example: "Pre-op physical therapy x 2-4 weeks focused on achieving full extension and quadriceps activation. Medical clearance from PCP given diabetes. Continue metformin until night before surgery."

4. Durable Medical Equipment (DME):

   • Bracing specifications
   • Assistive device prescription
   • Post-operative equipment needs
   • Example: "Post-operative hinged knee brace. Cryotherapy unit for home use. Crutches with non-weight-bearing instructions initially."

5. Physical Therapy Referral:

   • Specific protocol or goals
   • Frequency and duration
   • Communication with PT
   • Example: "Post-operative ACL reconstruction protocol. PT 3x/week starting POD #1. Focus: ROM, quad activation, edema control. Copy of protocol sent to PT."

6. Injection Therapy (if indicated):

   • Type of injection (corticosteroid, viscosupplementation, PRP)
   • Technique (landmark vs. ultrasound-guided)
   • Post-injection instructions
   • Example: "Intra-articular corticosteroid injection discussed as temporizing measure but patient declines, prefers surgical management."

7. Work/Activity Restrictions:

   • Specific restrictions
   • Expected duration
   • Return-to-work/sport criteria
   • Example: "Off work for 2 weeks post-operatively. Light duty (desk work) at 2-4 weeks. Full duty as electrician at 4-6 months pending functional recovery."

8. Medications:

   • Pain management plan
   • DVT prophylaxis
   • Antibiotic prophylaxis
   • NSAIDs (with cautions for bone healing)
   • Example: "Post-op: Oxycodone 5mg Q4-6H PRN x 7 days, Aspirin 325mg BID x 2 weeks for DVT prophylaxis, Cephalexin 500mg QID x 5 days"

9. Patient Education:

   • Diagnosis explanation
   • Treatment options discussed with risks/benefits
   • Expectations and timeline
   • Warning signs to report
   • Example: "Discussed ACL tear diagnosis, natural history, and treatment options. Explained surgical technique, risks including infection, DVT, stiffness, graft failure, and anesthesia risks. Reviewed rehabilitation timeline and expectations. Patient demonstrates understanding."

10. Follow-up:

    • Timing of next appointment
    • Pre-operative visit requirements
    • Post-operative visit schedule
    • Example: "Pre-op visit in 3 weeks for consent, final planning. Surgery scheduled for 4 weeks. Post-op visits at 2 weeks, 6 weeks, 3 months, 6 months, 1 year."

Example Plan Section for Orthopedics

AI-Assisted Documentation for Orthopedics

As of 2025, 66% of healthcare providers utilize AI tools in their clinical practice. AI-powered documentation can significantly enhance orthopedic practice efficiency while requiring careful review of specialty-specific findings.

How AI Can Help with Orthopedic Documentation

• Examination capture: Accurately documents range of motion values, strength grades, and special test results
• Template generation: Creates structured notes with joint-specific examination formats
• Surgical planning documentation: Captures operative planning discussions and consent conversations
• Imaging integration: Documents verbal interpretation of imaging findings
• Protocol adherence: Ensures standardized documentation elements are captured

Orthopedic-Specific AI Considerations

What AI captures well:

• Patient history and mechanism of injury
• Pain characteristics and functional limitations
• Treatment discussions and patient education
• Surgical planning and consent discussions
• Follow-up scheduling and instructions

What requires careful review:

• Laterality: Verify LEFT vs. RIGHT accuracy (critical for wrong-site surgery prevention)
• Range of motion values: Confirm exact degree measurements
• Special test results: Verify positive/negative findings and specific grading
• Strength grades: Confirm 0-5 scale accuracy
• Imaging interpretation: Verify fracture descriptions, ligament findings, measurements
• Surgical procedure names: Confirm procedure terminology and laterality

Tips for Using AI with Orthopedic Documentation

1. State laterality explicitly: "RIGHT knee Lachman test is positive" not "Lachman positive"
2. Dictate ROM values clearly: "Knee flexion is zero to one hundred twenty-five degrees" not "flexion 125"
3. Specify special test findings: "McMurray test is positive for pain and click with external rotation testing the medial meniscus"
4. Confirm imaging laterality: "MRI of the RIGHT knee shows ACL tear" - always include side
5. Verbalize measurements: "The fracture has fifteen degrees of apex volar angulation and fifty percent displacement"
6. Double-check surgical consent: Verify procedure name and laterality before signing

AI and Wrong-Site Surgery Prevention

Critical documentation points where AI requires verification:

• All references to laterality in subjective, objective, assessment, and plan
• Marking documentation: "Site marked with initials by surgeon"
• Consent form: Verify laterality matches throughout
• Imaging correlation: Confirm imaging reviewed is correct side

For more details, see our complete AI-Assisted Documentation Guide.

Telehealth Orthopedic Documentation

Telehealth has limited but important applications in orthopedic practice, particularly for pre-operative consultations, post-operative follow-up, and chronic condition management. Per CMS 2026 guidelines, telehealth services continue with specific documentation requirements.

Appropriate Telehealth Orthopedic Encounters

Well-suited for telehealth:

• Pre-operative consultations and consent discussions
• Post-operative follow-up (2+ weeks, wound healed, stable recovery)
• Chronic condition management (established osteoarthritis patients)
• Physical therapy progress reviews
• Medication management
• Second opinion consultations (with imaging available)
• Disability and work status evaluations

Not appropriate for telehealth:

• Initial trauma evaluation
• Acute injuries requiring examination
• New patient consultations requiring comprehensive MSK exam
• Post-operative visits with wound concerns
• Joint injections or procedures
• Patients with concerning symptoms requiring hands-on evaluation

Telehealth-Specific Documentation Requirements

For virtual orthopedic visits, document:

1. Visit logistics:

   • Platform used (HIPAA-compliant)
   • Patient and provider locations
   • Consent for telehealth services

2. Modified examination:

   • What could be assessed via video
   • Patient-demonstrated ROM and function
   • Visual inspection findings
   • Gait observation (if patient can stand back from camera)

3. Examination limitations:

   • Clearly state what could NOT be assessed
   • Palpation, special tests, and strength testing limitations
   • When in-person visit is recommended

Example Telehealth Orthopedic Documentation

For complete telehealth documentation guidance, see our Telehealth SOAP Notes Guide.

Free Orthopedics SOAP Note Template

Speed up your documentation with our comprehensive orthopedics SOAP note template. This template includes all essential elements for orthopedic evaluations, surgical planning, and treatment documentation.

More Template Resources

• Free SOAP Note Templates - Download templates for all specialties
• Physical Therapy Guide - Rehabilitation documentation
• Emergency Medicine Guide - Acute trauma documentation
• SOAP Note Template Hub - Browse all available templates