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Orthopedic Documentation in Acute Care Hospitals Orthopedic patients are unique surgical patients since their underlying physical conditions,
operative
locations
and
co-morbidities
result
in
higher
risk
of
complications or adverse events compared to other surgical patients. Due to this, these patients are often admitted to acute care surgical units. However, proper clinical documentation is essential for acute care hospitals to provide urgent and high quality care. The documentation involves four major reports, the history and physical examination report, the consultation report, the operative report and the discharge summary.
History and Physical Examination Once the patient is admitted to the hospital, the physician should take the patient’s history soon and carry out a physical examination. The findings should be documented according to the category, which usually include:

Chief complaint (presenting problem)

History of present illness (events that led to the hospitalization)
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Past medical history (any medical and surgical problems from childhood to present, medications, allergies)
Family history (medical condition of parents and other family members)
Social history (patient’s occupation, lifestyle, habits)
Review of systems (an inventory of the patient’s symptoms by system)
Physical examination (findings on examination of patient)
The physical examination details are recorded with the subheadings – general appearance, vital signs, skin, HEENT (head, eyes, ears, nose, and throat), chest, breasts, heart, lungs, abdomen, back, extremities, genitalia or pelvic, rectal, and neurologic. The admitting diagnosis and a brief description of the proposed treatment (treatment plan) should also be included in the history and physical examination report.
Consultation Consultation report is required when the orthopedic surgeon is asked to consult the patient of another physician to give an opinion on the treatment and diagnosis of an orthopedic condition. This report contains the following:
Brief history of the patient’s illness
The physical findings
Pertinent laboratory work
Working diagnosis
Suggested course of treatment
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Operative A detailed, documented report of the operation is essential when an orthopedic surgical procedure is performed. The operative report includes the following details:
Date of operation
Duration of anesthesia and operating times
Names of the operating surgeon and assistants
Preoperative and postoperative diagnoses
Title of operation performed
Type of anesthesia provided
Specimens sent to pathologists
Indication for surgery
Operative findings
Detailed description of the operation
The detailed description of the surgical procedure should include estimated blood loss, suture materials used for closing the incision, complications encountered, the patient’s condition at the end of the procedure. The details of tourniquet time, blood and/or fluid replacement, drains placed, and medications administered are included, if applicable. Postoperative plan is also documented by certain surgeons.
Discharge Summary Different treatment modalities are performed when a patient is ready to be discharged from the acute care hospital. Preparing discharge summary is very important at this stage. This report summarizes a patient’s course in the acute care
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www.medicaltranscriptionservicecompany.com hospital and is often documented just before and just after the discharge. The following information is included in this report.
Dates of admission and discharge
Admission and discharge diagnoses
Procedures or operations performed (if any)
Brief review of the patient’s history and physical examination findings
Laboratory work performed and pertinent findings
Details of patient’s hospital course including treatment modalities
Discharge medications
Discharge plan or disposition
Acute care hospitals can use electronic health record systems to enter all these details quickly and dedicate more time to provide quality care. However, errors may occur from frequent copy pasting and limitations to narrative description pose a greater challenge to electronic documentation. In such a scenario, EHR transcription is more efficient to achieve comprehensive and complete documentation. In this approach, skilled and experienced transcriptionists are employed to transcribe physicians’ dictations and the transcribed data is populated into the appropriate fields. EHR transcription service can be obtained from a professional medical transcription company. Go for a provider that is established in the industry and has certain distinguishing features that make them stand apart from competitors. Look for service features such as excellent team of transcriptionists, editors and proofreaders, multilevel quality checking, customized turnaround time, cost savings, and competitive pricing.
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