The Trauma Register ©

Physician Followup Data Entry

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Sample entry of follow-up input (open, comminuted femoral shaft fracture)

Program features

Prompted, consistent follow-up entry

ICD-9 diagnosis-specific follow-up protocols are offered in accordance with Gustilo RB; The Fracture Classification Manual; Mosby Year Book 1991

More extensive physician follow-up data entry routines (than that demonstrated in the video clip at the top of this web page) are available. These routines enable Workmans Comp grade AMA Permanent Residual Impairment ratings as well as the following outcome scoring methods from the medical literature:

Shoulder
	Gustilo, The Fracture Classification Manual, p 153)
	American Shoulder Surgeons Score (JBJS 69A 867)
  
Elbow
	HCMC Score (Gustilo, The Fracture Classification Manual, p 153)
	HSS Elbow Score (JBJS 62A 1254)
	Mayo Elbow Score (JBJS 74A 480)
	Elbow Functional Rating Index (JBJS 68A 670)
  
Hand/Wrist    
	HCMC Score (Gustilo, The Fracture Classification Manual, p 153)
	Modified Green-O'Brien Score (J Hand Surg 18A 770)
	
Pelvis/Hip
	HCMC Score (Gustilo, The Fracture Classification Manual, p 153)	
	Harris Hip Score (JBJS 51A 737)
	Mayo Clinical Hip Score (CORR 193 133)
	Iowa Hip Score (CORR 31 451)
	D'Aubigne-Postel Hip Score (JBJS 36A 451)
	Modified D'Aubigne-Postel Hip Score (CORR 205 244)
	Iowa Pelvic Score (CORR 329 181)
	Majeed Pelvic Score (JBJS 71B 305)
	Orlando Pelvic Score (CORR 329 178)

Knee
	HCMC Score (Gustilo, The Fracture Classification Manual, p 153)
	HSS & Knee Society Score (CORR 248 13)
	Iowa Knee Score (JBJS 71A 600)
	Tampa Knee Score (JOT 3 217)
	Neer Knee Score (JBJS 49A 591)
	Modified Larsen Knee Score (AJSM 10 151)
	Lysholm Knee Score (CORR 198 44)
	Marshall Knee Score (CORR 123 115)
	Noyes Knee Score (JBJS 72A 1127)
	
Foot/Ankle
	HCMC Score (Gustilo, The Fracture Classification Manual, p 153)
	Mayo Ankle Score (CORR 215 191)
	Iowa Ankle Score (JBJS 71A 601)
	Teeny/Wiss Ankle Score (CORR 292 110)
	Phillips Ankle Score (JBJS 67A 72)
	Mazur Ankle Score (JBJS 61A 964)
	Modified Olerud/Molander Ankle Score (JBJS 75A 343)
	Tampere Finland Ankle Score (AJSM 22 465)
	Maryland Foot Score (CORR 290 90)
	HSS Foot Score (JBJS 74A 566)
	
Spine
	Scoliosis Research Society Score (Spine 17 528)
	American Spinal Injury Association Score (CORR 288 166)

Facilitated distribution and non-duplication of clinical documentation

Trauma Register follow-up data entry can be configured to either print hard copy or to send via FTP or e-mail to the Hospital Information System and Medical Records in order to avoid a duplication of clinical documentation. The same option applies to the History and Physical Exam and the Discharge Summary. Referring physicians may be cc'ed on these transmissions.

The following schematic shows the savings in terms of time and transcription fees of this entry mechanism (i.e. TR pathway) relative to a conventional clinic documentation (present) mechanism at Vanderbilt,.

Clinic Descriptors Derived

All visits may be CPT4 and HCFA RVU (Relative Value Unit) Classified