A musculoskeletal note built on the mechanism of injury, laterality every time, a distal neurovascular check, and a decision rule for imaging.
By Francisco Sanchez, BSN, RN · ER nurse and FNP student · Updated October 2026
Setting: Outpatient urgent care or sports medicine visitPatient: Fictional patient: 27-year-old woman, recreational soccer player
SSubjective
Chief complaint
Right ankle pain. "I rolled my right ankle playing soccer."
HPI
Yesterday at 18:00, landed from a header and rolled the right foot inward (inversion, foot pointed down). Felt a pop, then immediate pain and swelling on the outside of the ankle. Able to take 4 steps with a limp right after the injury and on arrival today. Pain 6/10, worse with weight bearing; has iced and elevated it. No numbness or tingling, no knee or foot pain, no prior right ankle injury.
Activity / occupation
Recreational soccer twice a week. Dental hygienist, on her feet most of the day.
OObjective
Inspection
Right ankle: moderate swelling and bruising over the lateral malleolus; no deformity; skin intact.
Palpation
Tender over the right anterior talofibular ligament. No bony tenderness at the posterior edge or tip of either malleolus, the base of the 5th metatarsal or the navicular. No proximal fibular tenderness.
Range of motion / strength
Dorsiflexion and plantarflexion limited by pain; inversion painful. Strength 5/5, pain-limited eversion.
Neurovascular
Right foot: dorsalis pedis and posterior tibial pulses 2+, capillary refill under 2 seconds, sensation intact to light touch in all nerve distributions, toes move normally.
Special tests
Anterior drawer: mildly increased laxity compared with the left, firm endpoint. Talar tilt negative. Squeeze test negative (no high ankle sprain). Thompson test negative.
Imaging
Ottawa ankle rules negative (able to bear weight 4 steps; no bony tenderness at the malleoli or midfoot), so no X-ray indicated.
AAssessment
Diagnosis
Right lateral ankle sprain, grade II (anterior talofibular ligament), inversion mechanism. Fracture unlikely by Ottawa ankle rules. No syndesmotic (high ankle) injury. Neurovascularly intact.
PPlan
Immobilization / weight-bearing
Lace-up ankle brace. Weight bearing as tolerated; crutches for 2-3 days if needed.
Pain control
Ibuprofen 600 mg by mouth every 6 hours as needed with food, for up to 5 days. Ice 15-20 minutes every 2-3 hours for the first 48-72 hours; compression and elevation.
Follow-up / referral
Early range-of-motion exercises after 48-72 hours, then balance training. Return to soccer when hopping and cutting are pain-free, usually 3-6 weeks, wearing the brace. Recheck in 1-2 weeks; physical therapy referral if not improving.
Return precautions
Numbness, color change or a cold foot; pain or swelling that keeps getting worse; inability to bear weight or new bony tenderness (X-ray then needed).
Fictional patient, written for learning. Follow your program's and facility's documentation standards.
Why this note works
The mechanism is described exactly (inversion, foot pointed down), which predicts the injured ligament.
Laterality appears in every section.
The neurovascular exam distal to the injury is documented in full.
The decision not to X-ray rests on a named decision rule, with each criterion documented.
What students often miss
Hand dominance for upper-extremity injuries
Distal pulses and sensation
Ability to bear weight
Orthopedics SOAP note template
How it happened, what's injured, and whether the limb is safe.
SSubjective
Chief complaint
With side.
HPI
Mechanism, time, ability to bear weight, swelling, numbness, prior injury.
Hand dominance
For upper-extremity injuries.
Activity / occupation
OObjective
Inspection
Swelling, deformity, bruising, skin integrity.
Palpation
Bony tenderness.
Range of motion / strength
Neurovascular
Pulses, capillary refill, sensation, motor, distal to injury.
Reading examples helps. Writing your own note and seeing exactly what you missed is what makes you better. SOAPy gives you a realistic case and checks your note section by section.