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Spine Patient Records

What does the Spine Specialists document in a Spine Consultation?

A spine consultation is performed by a spine specialist. The consultation usually includes the following parts:

  1. The patient’s history which includes information about their symptoms, medical history, prior diagnostic studies and treatments
  2. The results of the examination
  3. A diagnosis, or a list of potential diagnoses

What does the Spine Specialist document in an Office Note?

Office notes can vary as to what information the spine specialist documents. The following may be part of the note:

  1. Reason for the visit. i.e. why is the patient being seen in the office
  2. What symptoms is the patient experiencing
  3. The status of the symptoms the patient is experiencing, i.e. is he patient better, same or worse
  4. Any new information, such as the results of new studies (labs, imaging, etc.) or new medications the patient is taking.
  5. Results of an examination
  6. A diagnosis
  7. A plan of what should be done, i.e. scheduling an injection or surgery, starting a new medication, etc.

What does the Spine Specialist document in a Preoperative History and Physical Examination?

A Preoperative History and Physical is required before an type of procedure or surgery. Here are some of the items typically included:

  1. Patient name, date of birth, medical record number
  2. Doctors name
  3. Date
  4. General description why the patient needs the procedure or surgery
  5. The patient’s past medical history
  6. The patient’s past surgical history
  7. Patient allergies
  8. The medications a patient is taking
  9. The social history, such as smoking habits, alcohol consumption, drug use
  10. A “Review of Systems”. This is a review of the different organ systems and whether a patient has any symptoms. Here are some examples of what is included:
  • Pulmonary (lung): whether a patient has had a recent cough or lung infection
  • Cardiac (heart): whether a patient has had recent chest pain
  • Neurological: whether a patient is suffering from weakness or numbness in the arms or legs
  • Gastrointestinal (stomach and intestines): whether a patient has had a recent intestinal infection, diarrhea or constipation.
  • Genitourinary (genitals and urinary tract): whether a patient had symptoms of a recent urinary tract infection.

   11. A physical examination. Here are some examples of what is done on  the physical examination:

  • Vital signs measured: heart rate per minute, blood pressure, breathing rate per minute, body temperature, height and weight
  • Examination of the head and neck
  • Examination of the chest and lungs
  • Examination of the heart and blood vessels
  • Examination of the abdomen
  • Examination of the arms and legs                                                                                                               

   12. An impression of the patient’s overall health, possibly including health risks for surgery based on the overall health status.

   13. A plan for what type of procedure or surgery should be done.                                                                                                                                          

 What does the Spine Specialists document in an Operative Report (Surgery Report)?                                                                                                                                            

Operative Reports are important documents since they describe the surgery in detail.

The following are common parts of an operative report:

  1. Date of the report
  2. Name, age, date of birth and other identifiers of the patient
  3. Name of the surgeon
  4. Name of the Anesthesia provider
  5. The name of the referring physician if any
  6. The patient’s spine symptoms, history and prior failed treatments
  7. A diagnosis
  8. The reason for the surgery and any potential alternatives to surgery
  9. That risks and benefits were explained prior to surgery and what they were
  10. That the patient was in agreement with the plan for surgery
  11. That a history and physical examination was completed before surgery
  12. The type of anesthetic used for surgery
  13. Medications given prior to and during surgery
  14. The position the patient was placed in for the operation, i.e. on their back (supine) or stomach (prone)
  15. The type of padding used during surgery to avoid an injury caused by compression of a part of the body
  16. The preparation of the surgical site to sterilize the skin
  17. Any local anesthetic used on the skin
  18. Time of the incision
  19. The type of knife blade used for the incision
  20. How the spine was exposed, i.e. instruments such as types of retractors used
  21. What structures were removed or incised
  22. What the surgeon visualized about the problem, i.e. “the disc had a large herniation”
  23. How the problem was fixed and the instruments used
  24. If anything was implanted or an implant removed from the spine
  25. If any type of medication was given or fluid injected into the wound
  26. How the wound was closed, i.e. the types of stitches (sutures) used
  27. If any local anesthetic was injected at the end
  28. How the skin was closed, i.e. staples or sutures
  29. What type of dressing was used on the wound
  30. Time when the wound was closed
  31. How the patient tolerated the surgery
  32. How the patient tolerated the anesthesia
  33. Blood loss for the surgery
  34. Intravenous fluid given during surgery
  35. How much urine was produced by the patient during surgery (if a catheter was placed into the bladder)
  36. If the diagnosis remained the same after surgery as it was before surgery. Sometimes something new is found during surgery that needs to be annotated
  37. If any complications occurred during surgery
  38. Condition of the patient at the end of surgery, i.e. ‘stable’ or not
  39. The postoperative plan for the patient, i.e. will the patient be admitted to the hospital, for approximately how long and what type of postoperative care will be provided.

What does a Spine Specialist document in a Procedure Note?

Procedure reports such as reports of injections are similar to Operative Reports, but may be shorter and more focused. The following are some typical items which are reported:

  1. Date of the procedure
  2. The age and name of the patient and other identifiers
  3. The symptoms and diagnosis of the patient
  4. That a consent for the procedure was obtained before the procedure
  5. That risks and benefits as well as alternative to the procedure were obtained
  6. The type of anesthetic given and how much, i.e. types of medications
  7. The type of procedure performed
  8. How the procedure was performed
  9. If anything was injected or delivered to the patient
  10. If there was a complication
  11. How the patient tolerated the procedure
  12. What the plan is after the procedure
  13. When the patient will be seen again

What does the Radiologist document on an Imaging Report?

Imaging reports are generated by the radiologist, not the spine specialist. The information on the report will depend on the type of imaging done, i.e. X-Rays, MRI, CT-Scan, etc.

However the following are usually part of the report

1. Date of the procedure

2. Medical Record Number

3 Name and date of birth of the patient

3. Any information known about the patient’s history which prompted the imaging study

4. The type of study performed

5. If any medication is given to the patient, i.e. contrast material intravenously

6. The interpretation of the study

7. A conclusion which is a summary of the finding

8. Name of the radiologist

What does the Spine Specialist document in a Progress Note?

Progress notes are hospital records which are generated every 24 hours to summarize the care provided after surgery. The following are some of the items found in progress reports:

  1. Date and time of the note
  2. The number of days after surgery and the type of surgery performed
  3. Subjective: What the patient reports to the doctor, i.e. type and amount of pain, the patient’s mood, any complaints, etc.
  4. Objective: The vital signs, amount of fluid delivered to the patient and excreted by the patient, lab results, imaging results, etc.
  5. Assessment: The patient’s diagnosis, whether he/she are improving or worsening, etc.
  6. Plan: What is planned for the next 24 hours, i.e. imaging studies ordered, change in intravenous fluids, medications, physical therapy, potential for discharge from the hospital, etc.

What does the Spine Specialist document on a Discharge Summary (Hospital Discharge)?

Discharge summaries are official records of the important events of a patient’s hospital stay.

The following information may be found on discharge summaries:

  1. Date of the dictation
  2. Patient’s name and identifiers
  3. Name of the doctor dictating the report
  4. Date of admission to the hospital
  5. Date of discharge from the hospital
  6. Procedures/surgeries performed during the hospital stay
  7. Condition of the patient on admission and on discharge
  8. Diagnoses established during the admission
  9. Types of studies performed during the admission
  10. Complications encountered
  11. Consultations obtained from other specialists
  12. Medications given