Orthopedic Injury Assessment Form

The Orthopedic Injury Assessment Form provides a systematic framework for evaluating acute and chronic musculoskeletal injuries across all anatomic regions. It captures detailed mechanism of injury information (fall, motor vehicle collision, sports contact, overuse, work-related), injury timing and progression, and the patient's immediate functional limitations. The musculoskeletal examination section documents inspection (deformity, swelling, ecchymosis, open wounds), palpation (point tenderness, crepitus, effusion), active and passive range of motion measurements using goniometry, strength testing against resistance using the Medical Research Council (MRC) grading scale, and joint-specific provocative tests (Lachman, McMurray, Thompson, Ottawa ankle rules, Phalen, Tinel, Hawkins-Kennedy, empty can test).

This template includes comprehensive neurovascular assessment documentation covering distal pulse quality, capillary refill, sensation in dermatomal distributions, and motor function of nerves at risk for the specific injury location. It accommodates imaging documentation including radiograph interpretation (fracture classification using AO/OTA or Salter-Harris systems, joint alignment, hardware position), advanced imaging orders (MRI, CT, bone scan), and point-of-care ultrasound findings. The treatment section captures immobilization type and position, reduction maneuvers performed, weight-bearing status orders, and surgical versus non-operative management decision rationale.

Designed for orthopedic surgery practices, emergency departments, urgent care centers, and sports medicine clinics, this form supports documentation requirements for workers' compensation claims, personal injury cases, and return-to-play clearance decisions. It provides the structured clinical data needed for surgical planning consultations, fracture clinic follow-up tracking, and outcome measurement using validated patient-reported outcome measures (PROMs) such as the DASH, KOOS, or PROMIS physical function scales.