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THE HAND ASSESSMENT PRO‐FORMA: IMPROVED COMMUNICATION AND DOCUMENTATION FOR BETTER MEDICAL AND LEGAL OUTCOMES
Author(s) -
Kapila S.,
Kapila H. B.
Publication year - 2009
Publication title -
anz journal of surgery
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.426
H-Index - 70
eISSN - 1445-2197
pISSN - 1445-1433
DOI - 10.1111/j.1445-2197.2009.04918_5.x
Subject(s) - documentation , pro forma , medicine , senior house officer , referral , medical emergency , emergency department , accident and emergency , phone , chart , medical education , nursing , computer science , linguistics , philosophy , statistics , accounting , mathematics , business , programming language
Hand cases are common presentations to Emergency Departments and often pose complex clinical challenges in assessment especially by junior doctors. The purpose of the hand assessment pro‐forma is to arm the examining doctors with skills for better assessment, management and documentation of hand cases. Upon surveying 20 metropolitan emergency departments, it was found that only two had hand specific reference material, four had orthopaedic or general surgical texts, and the rest had only emergency texts immediately available to the perplexed junior doctor. The high demands of emergency departments increase the need for more efficient hand injury management and referral to equally busy on‐call hand services. This standardized, universal, user‐friendly hand assessment pro‐forma proficiently records each component of the assessment in a two‐page examination chart. This ensures timely and complete documentation as it guides the medical officer through assessment in a step wise manner. The assessment pro‐forma, including the diagrams, can be faxed to the on‐call hand surgeon at the time of referral. Through improved communication and reduced reliance on cumbersome oral description, greater understanding of a case discussed over the phone will allow early intervention, optimised outcome, and minimised costs. Maximum expected standards of documentation are achieved with the completion of each part of the pro‐forma, which reduces possible medical and legal complications. A readily implemented and simple model with potential for aid to junior doctors is now available which increases efficiency for emergency departments, allowing thorough assessment of patients with reduced hospital costs and risks of litigation.