Table A1
EXOGEN device suitability screening tool to be used to assess patient suitability prior to commencing EXOGEN and assessing for successful completion post-treatment.
EXOGEN® ultrasound bone healing system used for the management of long bone non union fractures | |||||
---|---|---|---|---|---|
Patient NHS No. | Trust: | GP Name: | |||
Patient Hospital Number: | Consultant Making Request: | GP code/Practice code: | |||
Patient initials | |||||
Date of birth | // | GP Post code: | |||
Please confirm the following | |||||
The patient is over 18 years old. | Yes | No | |||
|
Yes | No | |||
|
Yes | No | |||
|
Yes | No | |||
For treatment failures, the provider will ensure that a reimbursement is obtained in accordance with the manufacturers “money back guarantee” arrangement; the CCG will not fund these patients. | |||||
I confirm that the patient meets the criteria for treatment | I confirm that the patient meets the criteria for treatment | ||||
Name of consultant: | Signature (or email confirmation) by Department Service Manager (or nominated deputy) | ||||
Signature: | Name: | ||||
Date: // | Signature: Date: // | ||||
Section below to be submitted on completion of treatment | |||||
Treatment was successful | Yes | No | |||
If no, seek reimbursement from the manufacturer Cost of EXOGEN® claimed £ | |||||
Time to heal/fail (weeks) Date final assessment // | |||||
I confirm that the patient meets the criteria for treatment | I confirm that the patient meets the criteria for treatment | ||||
Name of consultant: | Signature (or email confirmation) by Department Service Manager (or nominated deputy) | ||||
Signature: | Name: | ||||
Date: // | Signature: Date: // |
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