Orthopaedic clinic software: from the injured joint to the cast sheet the patient takes home

An orthopaedic clinic sees the same knee several times: after the injury, after the scan, after the plaster comes off. A handwritten card copes with the first visit; by the third, the gaps show:

• The side goes missing. “Lachman positive” without a side cannot be relied on next time.
• “Movement reduced” replaces degrees. Whether flexion went from 90° to 120° in six weeks is lost.
• Negative and not done look alike. A test never tried and one impossible with a tense effusion both end up blank.
• The fracture lives on a sketch. A line on a photocopied skeleton says little about pattern, displacement or an open wound.
• Cast advice is spoken, not written. The patient leaves without knowing which signs mean coming back at once.

A good orthopaedic record keeps the side, the number and the instruction, so the next clinician reads facts, not impressions.

Settle first what each visit must capture. This list holds for any system, paper included:

A typical visit in the Orthopaedics department of OPALEVI for clinics: an unstable, painful knee two weeks after a sports injury. Words in bold are the program's own labels.

1. 1

   Booking

   Add appointment books the slot. Its tick Email the patient a reminder the day before works once the file holds an email address. When the patient arrives, the desk presses Send to the clinician.

2. 2

   Vital signs

   A nurse fills in Vital signs; Mark ready for the doctor then tells the surgeon the patient is waiting. Only the clinician writes the clinical record.

3. 3

   Complaint and region

   Write the history under the Doctor's report, then open the Orthopaedic examination: type the Joint / segment, choose the Side and record Pain (0–10).

4. 4

   Measure and test

   Fill in Range of motion (degrees), grade Power on the MRC scale (0–5) for each side and mark the Special tests by side. Other tests go under Specific tests, your reading of the scan under Correlation with imaging.

5. 5

   Treat and instruct

   Choose the Immobilisation and fill in Cast, splint or brace: care and return to activity; add exercises to the Home exercise sheet, medicines to the Prescription, and a Referral letter if an MRI is needed elsewhere.

6. 6

   Finish

   Under Next steps, use Book a follow-up appointment and, if the clinic invoices, Invoice this visit.

A new visit opens empty: nothing is copied from the last one. Earlier visits are listed beside the record under Previous visits, with date, department, doctor and diagnosis, one click from the full note.

Range of motion on a protractor

Six movements, from flexion to external rotation, each take an active and a passive reading. Drag the arm on the small protractor, or type what your goniometer reads. With both readings in, the screen shows the Passive–active gap: one subtraction, and the only arithmetic in this record. A reading past the dial's −30° to 180°, such as −40° of extension in a fixed flexion, is kept as typed and marked as beyond the dial.

Power and special tests, right and left

Power on the MRC scale (0–5) lists fourteen movements, from shoulder abduction to ankle plantarflexion, in a column per side; only whole grades are accepted, so a 4+ goes in the notes. Special tests by side holds fifteen tests, from Lachman and McMurray to Neer, FABER and Thompson. Each cell is Positive, Negative or Not performed, and an empty one means the test was not tried.

Pain on the figure and across visits

The Pain map on the diagram is a body figure seen from the front, the back, both sides and the hands. Each numbered mark takes an Intensity (0–10) and a Character: Mechanical, Inflammatory or Neuropathic. The Pain across visits chart plots the pain score from this patient's earlier orthopaedic visits and today's, once there are two, with no target line. Vets get a figure drawn for each species (exotic and farm animal veterinary software).

Fracture maps for the upper and lower limb

Lower limb fractures shows the hip, knee and ankle of each leg; Upper limb fractures, the shoulder and elbow of each arm. Marks go on bones only: a tap on a tendon files the bone beneath it. Each mark records the Fracture pattern, the Displacement and Open or closed. A plain gap: the wrist, hand and forearm shafts are not mapped, so a distal radius fracture is written in words.

OPALEVI prints each paper from what the clinician wrote, adds no dose, date or restriction of its own, and prints no cast sheet for a visit that records neither a cast nor a cast instruction.

• Immobilisation care. General advice for any cast, splint or brace and the signs that mean coming back at once, labelled as general; then Your immobilisation: what was applied, the joint and side, the dates, weight-bearing, the checks and each return-to-activity line. An external fixator gets no plaster advice.
• Home programme. Up to twenty exercises with sets and repetitions, the precautions and a review date, above a Practice log the patient ticks daily.
• Instructions after the procedure. After a reduction or an injection: instructions by topic, wound care, warning signs, the next review and whom to call. The list starts empty.
• Prescription and referral letter. The letter carries the visit's diagnosis and therapy.

• Physiotherapy. With two or more departments, Refer to a department sends the patient to physiotherapy with a Clinical reason; it lands on the Referrals worklist, where Take it on books the first session. The physiotherapy clinic guide takes the course from there.
• Imaging. The orthopaedic record has no image viewer: your reading goes under Correlation with imaging; the radiology software guide covers the reporting side.
• Theatre. Operations and operative notes belong to the surgery department: see the hospital surgery and ward guide. A spinal case may go to neurosurgery (neurology software).
• Money. Invoices are on from registration; a clinic that does not invoice turns them off under Settings → Application menus.

At first, any colleague cleared to read clinical records can open an orthopaedic one. Record privacy, under Settings → Department setup, narrows them: with several departments to The department or to Only the clinician the record is assigned to; with one department, from Automatic to Only the clinician. Visit history stays closed to reception unless the clinic opens it, and to finance always. The Change history keeps each edit with its author and time.

Ask these of each program on your shortlist, ours too.

Current prices are on the pricing page, each module on the features page, and the department in one line on orthopaedics in OPALEVI. For invoices, data protection and the trial, read how to choose clinic software.

Register as a clinic and tick Orthopaedics (a hospital or rehabilitation centre adds it to its other departments); First steps on Today tracks the setup:

1. 1

   Services and letterhead

   Add your services and prices: the list starts with an orthopaedic consultation and a plaster cast at placeholder prices, so set your own and add the rest (an injection, a splint). Then Set up the report letterhead.

2. 2

   Your team

   Invite your colleagues: the nurse who applies casts, reception and any physiotherapist, each with a role.

3. 3

   One patient, every paper

   Record one real visit in full and read its cast sheet as the patient will.

4. 4

   The review

   At the follow-up, open Previous visits and measure the same movements again; the pain chart now has two points.