• Document:
  • Level of vertebral column, for example, L1
  • Displaced versus nondisplaced
  • Part of vertebra fractured, for example, posterior arch
• Document type of fracture, for example:
  • Type II dens fracture of the 2nd cervical vertebra
  • Type III spondylolisthesis of the 2nd cervical vertebra
  • Stable versus unstable burst fracture
  • Zone I-III or Type 1-4 sacral fracture
• Document the healing process
  • routine
  • delayed
  • nonunion
  • malunion
• Indicate the encounter type
  • Initial
  • Subsequent
  • Sequela

Adult (main)|Pediatrics (main)

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