Development of a software package for electronic documentation of orthopaedic x-ray findings.
Proper documentation of x-ray findings, including anatomical location, joint position, arthritis location with severity, fracture patterns, bone changes,changes from joint arthroplasty, and ICD-9 coding,are a vital aspect of the orthopedic surgeons' daily office task. While radiology software is available for certain templated studies, there is little in the way of orthopaedic electronic documentation other than templated "pick-lists" for common findings. The authors developed a software package with line drawings of a selected anatomical area that are color coded to divide individual bones into proximal interarticular,distal inter-articular, and shaft fractures. Each color coded section of a bone details both fracture patterns and bone changes possible for that area of the bone or joint. When a cursor is moved over each section of the bone, the various fracture patterns and bone changes then appear on the screen. The chosen fracture pattern, along with its associated description, is then electronically recorded coupled with its ICD-9 code including the specific digit when appropriate.
Dew
Douglas K
DK
St. Johns Shoulder, Knee and Joint Clinic, Palm Coast, FL, USA.
Halpern
Steven J
SJ
Micheals
Charles E
CE
D004282:Documentation / Q000379:methods; D006801:Humans; D038801:International Classification of Diseases; D016347:Medical Records Systems, Computerized; D009985:Orthopedics; D011859:Radiography; D012984:Software