• Document
  • Level on vertebral column (e.g., L1)
  • Open or closed
  • Displaced or non-displaced
  • Name of specific bone and site on bone
  • Fracture type (e.g., Type II dens fracture of the 2nd cervical vertebrae)
  • Fracture orientation (i.e., transverse, oblique, spiral)
  • Laterality
  • Healing process (delayed, malunion, nonunion, routine)
  • Any associated or underlying cause (e.g., osteoporosis)
• Indicate encounter type (initial, subsequent, sequelae)

Adult (main)|Pediatrics (main)

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