158 KB30 KB200220242011Burger, HelenaGelebešev, LaskoSchara, KarinVidmar, Gajletnik:16številka:2str. 6-14ISSN:1318-2129COBISSID_HOST:1372521URN:URN:NBN:SI:doc-IRRH9D1XslSlovensko društvo za medicinsko informatikoInformatica Medica Slovenicaambulantaanalizamedicinska dokumentacijaortopedijaSlovenijaAnaliza nujnih pregledov v ortopedski ambulanti v Ljubljani| Analysis of urgent cases at the Orthopaedic Outpatient Clinic in Ljubljana|Medical records of all patients referred as urgent cases to the Orthopaedic Outpatient Clinic in Ljubljana in July 2009 were reviewed. ICD diagnoses, diagnostic imaging procedures, modalities of prescribed physical therapy (PT), referral to physical and rehabilitation medicine (PRM) specialists, and duration of problems before the visit were examined. At least one PT was prescribed in 43% of the cases. The patient was referred to a PRM specialist in only 3% of the cases. The problems had lasted from one day to several years (median 1 month). Because many non-urgent patients suffering from chronic musculoskeletal diseases are referred to orthopaedic surgeons, co-operation with PRM specialist should be improved. Data quality, especially coding the diagnoses according to the ICD, should also be amelioratedNa podlagi pregleda dokumentacije smo ugotavljali, katere diagnoze po MKB so dobili bolniki, ki so bili napoteni v nujno ortopedsko ambulanto na Polikliniki v Ljubljani v juliju 2009, katere slikovne diagnostične preiskave in katere metode fizikalne terapije (FT) jim je ortoped predpisal, kako pogosto jih je napotil k specialistu fizikalne in rehabilitacijske medicine (FRM) ter kako dolgo so trajale bolnikove težave pred pregledom. Na 43% pregledov je bila predpisana vsaj ena FT. K specialistu FRM je bil bolnik napoten le na 3% pregledov. Težave so pred pregledom trajale od enega dne do več let (mediana 1 mesec). Ker smo potrdili, da so v nujno ortopedsko ambulanto pogosto napoteni bolniki s kroničnimi mišičnoskeletnimi boleznimi, bi bilo smiselno izboljšati sodelovanje med kirurgi ortopedi in specialisti FRM. Hkrati bi bilo potrebno izboljšati kakovost dokumentacije, zlasti dosledno dodeljevati diagnoze po MKBTEXTznanstveno časopisjejournalsSlovenian National E-content AggregatorNational and University Library of SloveniaSlovensko društvo za medicinsko informatiko