Fractures
Progression
- When did disease process start
- Initial versus subsequent visit
Location
- Location of fracture
- Laterality
Acuity
Name
- Open or closed
- Displaced or nondisplaced (unspecified defaults to displaced)
- Type of open long-bone fracture based on the Gustilo classification system-Type II, Type III-A, Type III-C, etc.
- Other related injuries-tendons, nerves, arteries, veins, etc.
- Healing progress-routine, delayed, nonunion, malunion, etc.
Necessary Procedures
- Surgical and nonsurgical interventions
Other
- Circumstances/activity surrounding the injury
Why
- If fracture is traumatic or nontraumatic and underlying cause
- All associated conditions-compartment syndrome, etc.
- Other comorbidities