General Considerations in Orthopedic Surgery

Although it may seem obvious, the history and physical exam are still important in the evaluation of the patient. Every office visit is a history and physical exam, whether a new or a return visit. The completeness of the history and physical has assumed new importance in view of the complexities required for compliance with federal regulations. Regulations require that a chief complaint be specified, and this must be clearly defined because it determines the direction for the rest of the history and physical. The history must address the key features of the problem, both to elucidate the medical problem and to cover the subsidiary requirements for billing purposes. The social history and past medical history are similarly important because they change billing codes without necessarily affecting outcome or success of care. The physical again must cover the essentials necessary for diagnosis, and frequently the confirmation of the diagnosis is based on physical exam, but such considerations as skin condition and blood supply must be documented, despite the fact that this process is also part of the surgical evaluation. The next step is imaging and laboratory exams. The most important point here is to use the most cost-effective examination possible while keeping patient safety, satisfaction, and convenience in mind.