Microsoft word - hip fracture primary operation form1.doc
Year, month, day and 4 digit security number
1= Male 2= Female.
(see figure on the back of this form)
1=Undisplaced cervical fracture 2=Displaced cervical fracture 3= Basocervical fracture 4= Trochanteric two fragments fracture
5= Trohcanteric fracture multi fragments 6=Subtrochanteric fracture
Q374. Time of fracture
(if it is not known use day of admission) 24 hours clock
Q139. Time of admission
Q140 Time of first pain relief
Q141. Time of Xray
1 Own home 2=Sheltered housing 3= Institutional care 6=Rehabilitation unit 7= Acute hospital 8=Other
1=Yes 2=No 3=Institutional care (category 3-7 above).
1= Walked alone out of doors 2= Walked out of doors only if accompanied 3= Walked alone indoors but not out of doors
4= Walked indoors only if accompanied 5= Unable to walk Q12. Walking aids
1 – Can walk without aids 2= One aid (stick, crutch, tripod or hemiwalker) 3 = Two aids 4=Frame/Rollator 5=Wheelchair/bedbound
1 Single screw, pin or nail 2= Two screws, pins or nails 3= Three or more screws, pins or nails 4= Single screw, pin or nail with side plate 5= Intramedullary nail 6= Hemiarthroplasty 7= Total hip arthroplasty 8= Conservative 9= Other (for more detailed se back on this form)
Q18. Date of Discharge or death from admission ward
Year/ Month/ Day
1 Own home 2=Sheltered housing 3= Institutional care 6=Rehabilitation unit 7= Acute hospital 8=Other 9=Deceased
At admission During hospital At discharge
Occurrence of pressure ulcers on buttock or sacrum Q144.
Occurrence of pressure ulcer on heel
Occurrence of pressure ulcerany other area Q146.
Q166 Is a validated risk assessment scale used?
1=Yes 2= No
Q153. On Warfarin
Q154. Kognitive status
1= Normal mental functioning 2= Suspect dementia/delirium 3=Dementia diagnose
Q147. Kognitive screening SPMSQ
see on the back of this form)
Q127. Superficial woid infection
Q378. Length ………….cm
Q128. Deep wound infection
Q 379. Weight ………….kg
Q 380 .BMI
(only analyzed by the own clinic)
(Year/ Month/ Day) Q159.
(Year/ Month/ Day)
(Year/ Month/ Day) Q162.
(Year/ Month/ Day)
24 hours clock)
Codes for ASA classification
1. A Completely fit and healthy person who is on no medication and has no medical illness (other than the hip fracture). They
obviously may have had medical problems in the past but these are now resolved.
2. The patient has some illness but this has no effect on normal daily activity and the patient has no symptoms related to this
condition. Examples of this are things such as hypertension on treatment.
3. These are patients who suffer from conditions such as diabetes mellitus, asthma, angina, respiratory diseases. Providing
however these conditions can be described as mild to moderate and only result in minimal symptoms with little restriction on the patients lifestyle.
4. This is more symptomatic illness causing everyday and severe restriction on the patients’ life style. Examples of such
conditions are severe chronic bronchitis, unstable diabetes, frequent angina.
5. Moribund. The patient is in such a poor physical state that he/she is not expected to live more than a few days.
Additional codes for Primary operation
Two Cancellous threaded screws (e.g. AO, Asnis)
Sliding hip screw with trochanteric side plate
Sliding hip screw with Medoff side plate
Long intramedullary nail (type unspecified)
Unipolar hemiarthroplasty (type unspecified)
Bipolar hemiarthroplasty (type unspecified)
Total hip replacement (type unspecified)
Conservative treatment (indication or method not specified)
Codes for Pressure ulcer classification
Partial thickness skin loss. The skin surface is broken resulting in an abrasion or crater.
Full thickness skin loss and extension into subcutaneous fat but not through underlying fascia.
Extensive destruction involving damage to muscle, bone or tendon.
Pfeiffer test Short portable mental status questionnaire (SPMSQ)
Scores below 7 (max = 10) are generally considered to be indicative of impaired mental function. This test should be administered to the patient on admission to the acute orthopaedic ward, if possible prior to operative procedure.
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Count backwards 20-1, (score 1 if no mistakes or subject corrects themselves spontaneously).
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * For the Ohio Civil Service Employees Association/AFSCME Local 11/AFL-CIO:David Justice, Staff RepresentativeMark E. Linder, Assistant General CounselOhio Civil Service Employees Association/AFSCME Local 11/AFL-CIOFor the Ohio Department of Rehabilitation and Correction:David J. Burrus, Labor Relati
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