|
(Author: Brent Jones – April 20th, 2005)
Orthopaedic consultation (6.1.3) Storyboard: ACL Injury (6.1)
David Lambert has been referred to an orthopaedic surgeon to assess his injured right knee. The consultation takes place three weeks later at the urban tertiary care hospital outpatient orthopaedic clinic.
Dr. Abram reviews the referral letter sent to him by David’s clinic partner to understand the reason for the consultation. He then takes a history of the current injury along with David’s past medical and surgical history. David reports a prior injury to a knee years ago, although he cannot recall which side was affected. He had that injury assessed by a different orthopaedic surgeon in a community office. Dr. Abram examines the knee, and then accesses David’s records. He views the x-ray image that was done shortly after the recent injury and confirms that there was no fracture. He chooses not to repeat the image. He also searches David’s records for information related to a prior knee injury. He obtains a consultation report from a colleague who described a mild injury to the opposite knee.
Dr. Abram’s diagnosis for the current injury is a complete ACL tear with possible medial meniscus tear. David is referred to a physiotherapist for rehab and Dr. Abram completes the appropriate paper referral form for this. He creates his record of the encounter in the hospital EMR and dictates a letter summarizing the consultation to the referring doctor.
The letter is typed by a transcriptionist and Dr. Abram reviews and signs it two days later.
Assumptions
· Able to search clinical records in EHR based on criteria such as diagnosis, type of injury/illness
Tables
|
History |
Physical exam |
|
Provisional diagnosis |
Management plan |
|
Allergies |
Medications |
|
Past medical history |
|
Patient name |
Patient birthdate |
|
History of present illness |
Past orthopaedic/surgical history |
|
Past medical history |
Medications |
|
Allergies |
Examination |
|
Provisional diagnosis |
Management plan |
This health service follows upon the ER Knee visit (see 6.1.2) and describes all the health service events taken during the patient visit at the urban tertiary care hospital outpatient orthopaedic clinic in the jurisdiction where the patient lives; he has been treated at the hospital in the past.
Each health service event takes place during a same period of time (e.g. without cut of time), in presence or not of involved client; the health service events can be grouped in a health service encounter.
| General Info | |
|---|---|
| Name | 6.1.3 Orthopaedic consultation Encounter Diagram |
| Type | Use Case Diagram |
