Introduction

By  Mille Vissing, MD, Mie Pilegaard Bjarnesen, BCs. med. and Mia Wangsmo Steffenssen, MD

This chapter concerns the Danish journal model that is used to structure the patient interview (anamnesis), physical examination, and documentation in the patient journal. It is the onset of every hospitalization and reflects both the previous and current medical status of the patient. The following instructions are specifically oriented toward plastic surgery and the patients admitted to this department.

Aim

In evaluating a surgical concern, gathering a patient’s medical history through anamnesis, and obtaining relevant information with a thorough physical examination is crucial. The various elements of the documentation will be relevant depending on what chief complaint the admission is concerning. It is important to keep the purpose of the documentation in mind and only include relevant information. Attaining and recording important medical information in concise and unambiguous terms is a valuable skill that takes practice to perfect.
It is paramount that the surgeon understands all aspects of the patient’s concern to better evaluate if surgery is viable and more importantly whether surgery will satisfy the patient’s needs. If proper alignment of expectations is not established preoperatively, a successful treatment from the surgeon’s perspective might be perceived differently by the patient. They may have expected a different, and possibly unrealistic, outcome e.g. smaller/non-existing scars, less postoperative pain etc. Proper investigation and documentation are, therefore, essential to securing optimal surgical treatments of patients. In addition, it is important to document all information given to the patient regarding treatment and possible outcomes, to ensure that the patient is well informed, and to avoid legal disputes concerning the level of information given.
Besides the surgical concern it is important to obtain knowledge of the patient’s general health to decide whether the patient is physically fit for anesthesia before surgery is considered an option.