Essential Information to Gather from a Patient Requesting an Orthopedic Referral
When a patient requests an orthopedic referral, you should gather comprehensive information about their pain, function, and prior treatments to ensure appropriate referral and optimize outcomes for morbidity and mortality.
Key Assessment Areas
1. Pain Assessment
- Location: Exact joint(s) or area(s) affected
- Duration: Acute vs. chronic (how long have symptoms been present)
- Intensity: Using numerical pain scale (0-10)
- Character: Sharp, dull, aching, burning, etc.
- Aggravating and alleviating factors
- Timing: Constant vs. intermittent, worse at certain times of day
- Impact on daily activities and sleep
2. Functional Assessment
- Limitations in activities of daily living 1
- Impact on work or occupation
- Physical activity level and limitations
- Use of assistive devices (canes, braces, etc.)
- Ability to perform specific movements (range of motion)
- Gait abnormalities or instability
3. Prior Treatments and Their Effectiveness
- Conservative management attempts 1:
- Medications tried (analgesics, NSAIDs, etc.)
- Physical therapy (type, duration, and results)
- Activity modifications
- Weight management efforts (if applicable)
- Braces, orthotics, or assistive devices used
4. Medical History Relevant to Orthopedic Condition
- Previous injuries to the affected area
- Prior surgeries or interventions
- Relevant comorbidities (diabetes, cardiovascular disease, etc.)
- Current medications and allergies
- Family history of similar conditions
5. Patient Expectations and Goals
- What does the patient hope to achieve with orthopedic referral? 2
- Is the patient interested in surgical intervention if indicated? 3
- Understanding of potential treatment options
Specific Conditions Requiring Assessment
For Joint Pain (Potential Osteoarthritis)
- Assess BMI (weight management is crucial for OA) 1
- Document specific functional limitations
- Determine if patient has received education about their condition 1
- Evaluate if patient has tried core treatments for OA:
- Exercise/physical activity
- Weight loss (if overweight)
- Appropriate pain management strategies 1
For Potential Surgical Candidates
- Determine if symptoms substantially affect quality of life 1
- Assess if symptoms are refractory to non-surgical treatment
- Document duration and progression of functional limitations 1
For Spine Issues
- Presence of neurological symptoms (numbness, weakness, radiating pain)
- Red flags for serious pathology (fever, unexplained weight loss, etc.)
- Impact on bladder/bowel function
Documentation Requirements for Referral
- Imaging results (if already obtained) - note that MRIs are often not necessary prior to referral 3
- Previous specialist evaluations
- Detailed history of conservative management attempts
- Clear documentation of functional limitations
Common Pitfalls to Avoid
- Referring patients before adequate trial of conservative management
- Failing to document functional limitations (not just pain)
- Ordering unnecessary advanced imaging before specialist evaluation
- Not assessing patient's interest in potential surgical intervention
- Neglecting to evaluate weight management for joint conditions 1
- Overlooking psychosocial factors that may impact treatment outcomes 1
Remember that appropriate orthopedic referrals should follow a stepped-care approach, with core treatments attempted first for conditions like osteoarthritis, followed by specialist referral when these measures are insufficient 1.