Form 030268 – Fill Out and Use This PDF

The form 030268, commonly known as the Orthopaedic Surgery Encounter Form, is a comprehensive document used by healthcare providers to record various details of a patient's orthopaedic consultation or surgery. This includes information on patient history, diagnoses, procedures performed, and the level of care provided. Designed to ensure thorough documentation and facilitate billing processes, it covers aspects from chief complaints, history of present illness, to medical decision-making and follow-up appointments. For those needing to complete or request the 030268 form, click the button below to get started.

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Form 030268 PDF Details

For those navigating the complexities of orthopaedic surgery encounters within a healthcare setting, the Form 030268 stands out as a crucial document, meticulously designed to streamline the process of capturing necessary patient information, billing details, and clinical assessments. This form encompasses everything from patient demographics, such as name and medical record number (MRN), to specific details about the visit, including admission and discharge dates, injury date, referring physician, and much more. Beyond these foundational data points, Form 030268 delves deeper to gather insights on the patient’s chief complaint, history of the present illness, medical, social, and family histories, and a thorough review of systems. It is structured to guide healthcare professionals through a detailed examination, highlighting orthopaedic medical decision-making processes with numerical scores that inform the level of care and facilitating comprehensive consultations and procedural coding. Whether it’s for an initial visit or a follow-up, the form meticulously categorizes the encounter based on complexity and necessitates thoughtful completion by attending and resident physicians. This careful assembly of data does not only support accurate and efficient patient care management but also aligns with billing requirements, ensuring that all necessary information for reimbursement is captured, from diagnosis codes to procedure-specific codes for things like injections or fracture care. Thus, Form 030268 serves as an indispensable tool for orthopaedic practices, marrying clinical detail with billing efficiency to enhance patient care and streamline administrative processes.

Question	Answer
Form Name	Form 030268
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	UPIN, virginia, FSC, MUSCULOSKELETAL

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Orthopaedic Surgery Encounter Form

CHARGE CONTROL NO.

DIV. NO.

DIV. NAME

INVOICE NO.

MULT. SURG.?

FSC LIST

MRN

PATIENT NAME

ADMIT DATE

DISCHARGE

DATE

CASE

PROVIDER

FSC OVERRIDE

DISC

TYPE

REFERRING PHYSICIAN

UPIN

INJURY DATE

ADJ. AMT.

SVC. CTR.

RESIDENT

TIME

THRU DATE

REFERRAL #

LMP

ONSET

TREATMENT TIME

TYPE

BILLING AREA

LOCATION

SERVICE DATE

AUTHORIZATION

HOSPITAL

COMMERCIAL LAB

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS (HPI)

Was this an accident? If yes, what was the date and approximate hour of the day?

_____/_____/_____

Hour:___________

Work related?

οYes

ο No

Location Quality Severity

Duration

Timing

Context Modifying Factors

Associated Signs & Symptoms

PAST MEDICAL, SOCIAL, FAMILY HISTORY (PFSH)

III

MEDICAL (Illness, Operations, Injuries and Treatment)

SOCIAL (Review of Past & Current Activities)

οTOBACCO________________________ οETOH_________________________

οLIVING ARRANGEMENTS_____________________________

FAMILY (Review of Medical Events in Patient’s Family)

οCAD

οIDDM

οARTHRITIS

οCA

REVIEW OF SYSTEMS (ROS)

CONSTITUTIONAL

NO COMPLAINT ο

CARDIOVASCULAR

NO COMPLAINT ο

HEMATOLOGICAL/LYMPHATIC

NO COMPLAINT ο

RESPIRATORY

NO COMPLAINT ο

INTEGUMENTARY

NO COMPLAINT ο

PSYCHIATRIC

NO COMPLAINT ο

NEUROLOGICAL

NO COMPLAINT ο

MUSCULOSKELETAL

NO COMPLAINT ο

EARS/NOSE/THROAT/MOUTH

NO COMPLAINT ο

ALLERGIC/IMMUNOLOGIC

NO COMPLAINT ο

GASTROINTESTINAL

NO COMPLAINT ο

ENDOCRINE

NO COMPLAINT ο

EYES

NO COMPLAINT ο

GENITOURINARY

NO COMPLAINT ο

(2) Problem Focused: CC; 1-3 HPI elements

SCORE

(3) Expanded problem: CC; 1-3 HPI elements; 1 ROS

(4) Detailed: CC; ³ 4 HPI elements (acute) or ³ 3 HPI elements (chronic); 2-9 ROS; 1 PFSH element

(5) Comprehensive: CC; ³ HPI elements (acute) or ³ 3 HPI elements (chronic); 10+ ROS; 3 PFSH

elements (new or consult) or 2 PFSH elements (established)

Form # 030268 To reorder, log onto: http://www.virginia.edu/uvaprint/HSC/hs_forms.pl

VII

VIII

PHYSICAL EXAM

CONSTITUTIONAL – θMeasure any three of following vital signs			(2) Problem Focused: One to five elements identified by bullet
			(3) Expanded problem: At least six elements identified by bullet
Height________________________________ Weight__________________

BP Supine_________________		BP Sitting/Standing__________	(4)	Detailed: At least twelve elements identified				SCORE
				by bullet				SCORE
Pulse Rate_________________		Respiration _________________		by bullet
Temperature________________			(5) Comprehensive: All elements identified below

CARDIOVASCULAR ο Observation and palpation of peripheral vascular system			NEUROLOGICAL/PSYCHIATRIC
LYMPHATIC ο Palpation of lymph nodes in neck, axilae, groin/or other			ο Examination of Sensation		ο Examination of deep tendon reflexes
			ο Test Coordination		ο Orientation
MUSCULOSKELETAL ο Examination of gait and station			ο Test Coordination		ο Orientation
MUSCULOSKELETAL ο Examination of gait and station			ο Mood and affect
			ο Mood and affect

		JOINT EXAMINATION					SKIN

INSPECT 4 OF 6 AREAS		• Inspection, percussion, and/or palpation	•	Stability		•	Inspection, or
INSPECT 4 OF 6 AREAS		• Range of motion	•	Muscle strength, tone		•	Palpation
		• Range of motion	•	Muscle strength, tone		•	Palpation

ο Head and Neck

ο Spine, Ribs & Pelvis

ο L	upper extremity

ο R	upper extremity

ο L	lower extremity

ο R	lower extremity

MEDICAL DECISION MAKING: Circle the appropriate value in each column. Two of the three elements must be met or exceeded to achieve the level.

Number of possible Diagnoses or	Amount and/or complexity	Risk of Complications and/or		Type of Decision Making	Score

Minimal (1)	Minimal or None (<1)	Minimal	3	Straightforward	2

Limited (2)	Limited (2)	Low	3	Low Complexity	3

Multiple (3)	Moderate (3)	Moderate	3	Moderate Complexity	4

Extensive (4+)	Extensive (4+)	High	3	High Complexity	5

LEVEL OF CARE CALCULATION: Initial visit or consultation:	History	Orthopaedic	Medical Decision	LEVEL OF
score. Follow-up visit; remove lowest score. Choose next lowest.		Examination	Making	CARE

CIRCLE LEVEL OF VISIT

LEVEL 1

LEVEL 2

LEVEL 3

LEVEL 4

LEVEL 5

CONSULTATIONS

99241 (63110308)

99242 (63110316)

99243 (63110324)

99244 (63110332)

99245 (63110340)

CONFIRM CONSULT.

99271 (63110456)

99272 (63110464)

99273 (63110472)

99274 (63110480)

99275 (63110498)

NEW PT VISIT

99201 (63110357)

99202 (63110365)

99203 (63110373)

99204 (63110381)

99205 (63011399)

ESTAB. PT VISIT

99211 (63110407)

99212 (63110415)

99213 (63110423)

99214 (63110431)

99215 (63110449

PROCEDURES (CIRCLE, CHECK OR COMPLETE)

ASPIRATION/INJECTION

20600 (63121693)

20605 (63121685)

20610 (63121677)

20550 (63120042)

SMALL JOINT BURSA OR

INTERMEDIATE JOINT, BURSA OR

MAJOR JOINT

TENDON SHEATH, LIGAMENT,

GANGLION CYST

GANGLION

OR BURSA

TRIGGER POINTS OR CYST

INJECTABLE

99499 (63110118)

99024 (63110506)

DRUG TYPE:___________________________ AMOUNT_____________________________

PRE-OP H&P

POST-OP/VISIT

HCPCS Code:___________________________ SMS CODE:___________________________

FRACTURE CARE (Check and/or complete)

SITE_______________________________________________________

_____Without manipulation

_____ With manipulation

_____Initial Treatment Only

_____Follow-up Care Only

_____Open Treatment

CPT Code:___________________

SMS Code:___________________ Recasting (specify type)_______________________________________

Casting Material:

_____Plaster (A4580)

_____Fiberglass (A4590)

CPT Code:______________________

SMS Code:______________________

DIAGNOSIS

DX Code

Description

MISCELLANEOUS (Complete)

Description:___________________________________________________________

HCPCS CPT Code:___________________________________________________________

RETURN APPOINTMENT (SPECIFY):

WITHIN_______(WEEKS)

WITHIN_______(MONTHS)

OTHER_______

ATTENDING PHYSICIAN SIGNATURE:____________________________________________

RESIDENT FELLOW SIGNATURE:

Form 030268 – Fill Out and Use This PDF

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