Descriptor Guide For the Orthopedic Surgery Assessment Tool Version 2.0
The following items correspond to the Orthopedic Surgery Assessment Tool for BC. The descriptor statements are to be used as a guide when completing the tool. Please Note: Patient’s surgical condition should be assessed based on whether the patient is acute (injury or condition has occurred within the last six weeks) or chronic (injury or condition has been evident for more than six weeks)
Last Revised May 3, 2007 HA Procedure Code Procedure Description Date of Decision for Surgery The facility procedure code for the primary procedure that will be performed. Description of the primary procedure that will be performed. The date when the surgeon and patient decide to proceed with surgery.
Item 1: Usual FREQUENCY of symptoms (e.g. pain, fatigue, immobility), signs and suffering: 1. None 2. Occasional Currently, the patient does not experience pain or other forms of suffering associated with the surgical condition. The patient may experience occasional episodes of pain or other forms of suffering associated with the surgical condition. Pain and/or suffering are experienced once a week or less. Patient experiences episodes of pain or other forms of suffering associated with the surgical condition more than once a week but not sustained or constant. Patient is rarely free from pain or other forms of suffering associated with the surgical condition.
3. Often 4. Constant
Item 2: How INTENSE are the symptoms/suffering at their worst? In your response, consider how the patient would rate his/her level of symptoms/suffering associated with the surgical condition (e.g. pain, fatigue, immobility). 1. None 2. Mild - Currently, the patient does not experience, or has history of symptoms/suffering associated with the surgical condition. - Patient may experience symptoms/suffering. - Patient usually does not require pain medication. - Patient has no history of symptoms/suffering associated with the surgical condition that has necessitated emergency treatment. 3. Moderate - Patient may experience symptoms/suffering. - Patient may occasionally need pain medication. - Over the past 3 months, patient may have had one or more acute episodes of symptoms/suffering for which they requested emergency treatment. 4. Severe - Patient experiences symptoms/suffering most of the time. - Patient needs pain medication most of the time. - Over the past 3 months, patient may have had one or more acute episodes of symptoms/suffering for which they requested emergency treatment.
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Item 3: Usual INTENSITY of other (non-pain) forms of suffering such as psychological (e.g. stress, anxiety, depression). Please score the form of suffering with the greatest degree of severity. 1. None - Currently, the patient does not experience other (non-pain) forms of suffering. - Patient has no history of suffering associated with the surgical condition that has necessitated treatment. - Patient experiences suffering (non-pain) associated with the surgical condition. - Patient has not sought treatment for other forms of suffering associated with the surgical condition. - Patient experiences suffering (non-pain). - Patient has sought treatment for suffering associated with the surgical condition (e.g., anti-anxiety or anti-depressant). This treatment led to improvement in condition. - Patient experiences intense suffering associated with the surgical condition. - Patient has sought treatment for suffering (e.g., anti-anxiety or anti-depressant medication). This treatment did NOT lead to improvement in condition.
2. Mild
3. Moderate
4. Severe
Item 4: Degree of impairment in usual activities due to surgical condition (such as managing one’s family, relationships, work life and activities) due to condition. Refers to impairment in role function (e.g., job, housework, independence) or impairment in social activities (e.g., mobility, visiting friends/family, hobbies). 1. Not impaired at all/mildly impaired. 2. Able but difficult and/or somewhat impaired. 3. Able but very difficult and at much reduced level. 4. Totally dependent (unable to perform an usual activities) Currently, the patient can perform all of their daily activities without assistance. They may need to make some minor modifications in their daily routine or for certain tasks. Currently, the patient may need to make moderate adjustments in their daily routine (including limitations in work and recreational activities). Currently, the patient’s activities such as work and recreational activities are significantly reduced, but patient can perform self-care activities of daily living without assistance. Currently, the patient is unable to perform their usual daily work and recreational activities and requires assistance for all tasks, including self-care.
Item 5: Abnormal findings on physical exam: Refers to abnormal physical findings related to surgical condition. Do not include co-morbid conditions. 1. None/mild 2. Moderate 3. Severe Patient has a level of abnormal physical findings that do not significantly influence their surgical condition. Patient has a level of abnormal physical findings that somewhat influence their surgical condition. Patient has a level of abnormal physical findings that significantly influence their surgical condition.
Item 6: Potential for progression of disease without surgery. Ignore co-morbid conditions. 1. None 2. Mild. There is no clinical evidence that the patient’s disease or condition will worsen if the surgical procedure is not performed. There is clinical evidence that the patient’s disease or condition will somewhat worsen if the surgical procedure is not performed but the patient would not likely require emergency admission(s) or hospitalization(s). There is clinical evidence that the patient’s disease or condition will worsen if the surgical procedure is not performed and the patient may require emergency admission(s) or hospitalization(s). There is clinical evidence that the patient’s disease or condition will significantly worsen if the surgical procedure is not performed and the patient will likely require emergency admission(s) or hospitalization(s).
3. Moderate
4. Severe
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