• Document:
  • Name of specific bone and specific site on bone
  • Displaced versus nondisplaced
  • Open versus closed. For open fractures of the forearm, femur, and lower leg, document type by Gustilo classification (Type I, II, IIIA, IIIB, or IIIC)
  • Orientation of fractures, such as transverse, oblique, spiral
  • Laterality (e.g., right, left, bilateral)
  • Fracture type (e.g., traumatic, pathological, stress)
  • Other related injuries (e.g., tendons, nerves, arteries, veins, etc.)
  • Any associated or underlying cause (e.g., osteoporosis)
• Indicate the encounter type (initial, subsequent, sequelae)
• Document the healing process (routine, delayed, nonunion, malunion)

• Information regarding the activity, location, and circumstances surrounding the injury.

• For physeal fractures, document type according to Salter-Harris classification (Type I, II, III, or IV)

• For sacral fractures, document:

  • Zone I, II and III
  • Minimally versus severely displaced
  • Type 1, 2, 3, or 4

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.

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