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Download Fracture Documentation Guidelines General Identify episode of care
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Fracture Documentation Guidelines General Identify episode of care Initial Subsequent With routine fracture healing With delayed fracture healing With non-union of fracture Laterality Sequela of injury Place of occurrence of injury Activity of patient at time of injury Pelvis Identify fracture site/type Acetabulum Anterior column (iliopubic) Anterior wall Dome Medial wall Posterior column (ilioischial) Posterior wall Transverse Alone ( without associated posterior wall fracture) With associated posterior wall fracture Ilium Avulsion Other specified fracture of ilium Unspecified fracture ilium Ischium Avulsion Other specified fracture of ischium Unspecified fracture ischium Pubis Superior rim Other specified fracture of pubis Unspecified fracture of pubis Multiple fractures of pelvis With disruption of pelvic circle Stable Unstable Without disruption of pelvic circle Identify fracture status Displaced Nondisplaced Identify laterality – left, right Identify fracture as closed or open Humerus, Surgical Neck Identify site/type Greater tuberosity Lesser tuberosity 1 Surgical neck 2-part 3-part 4-part Unspecified surgical neck fracture Torus Fracture Other specified site, which includes Anatomical neck Articular head Identify fracture status Displaced Nondisplaced Identify laterality – left, right Identify fracture as closed or open Shaft of Radius and Ulna Identify type of radial/ulna shaft fracture Bent bone Comminuted Galeazzi’s fracture Greenstick Oblique Segmental Spiral Transverse Identify fracture status Displaced Nondisplaced Identify laterality – left, right Identify fracture Closed Open Gustilo Type I, II or open but not otherwise specified Gustilo Type IIIA, IIIB, IIIC Carpal Bones Identify site Capitate (os magunum) Hamate (unciform) Body Hook process Lunate Navicular (scaphoid) Distal pole Middle third Proximal third Pisiform Trapezoid (Smaller multangular) Trapezium (larger multangular) Triquetrum (cuneiform) Identify fracture status Displaced Nondisplaced 2 Identify laterality – left, right Identify fracture as closed or open Metacarpal Bones Identify metacarpal bones fractured First metacarpal (thumb) Other metacarpal bone Second Third Fourth Fifth For thumb, identify fracture site/type: Base Bennett’s fracture Rolando’s fracture Other fracture of base Neck Shaft For other metacarpal bones (second, third, fourth, fifth), identify fracture site Base Neck Shaft Other fracture Identify fracture status Displaced Nondisplaced Identify laterality – left, right Identify fracture as closed or open Neck of Femur Identify site of femoral fractures Neck Base of neck Epiphysis Intracapsular (subcapital), unspecified Midcervical Head Articular Other specified site Pertrochanteric Apophyseal Greater trochanter Intertrochanteric Lesser trochanter Subtrochanteric Identify fracture status Displaced Nondisplaced Identify laterality – left, right Identify fracture Closed Open Gustilo Type I, II or open but not otherwise specified 3 Gustilo Type IIIA, IIIB, IIIC Tibula and Fibula Identify lower leg bone Tibia Fibula Identify site/type of fracture Tibia upper end Condylar Lateral Medial Bicondylar (includes tibial plateau) Torus Tuberosity Other specified Tibial shaft Comminuted Oblique Segmental Spiral Transverse Fibular shaft Comminuted Oblique Segmental Spiral Transverse Identify fracture status Displaced Nondisplaced Identify laterality – left, right Identify fracture Closed Open Gustilo Type I, II or open but not otherwise specified Gustilo Type IIIA, IIIB, IIIC Physeal Fracture Identify bone Femur Fibula Humerus Radius Tibia Ulna Identify site Lower end physeal fracture Upper end physeal fracture Identify Salter-Harris classification Salter-Harris Type I Salter-Harris Type II Salter-Harris Type III Salter-Harris Type IV 4 Other physeal fracture Identify fracture status Displaced Nondisplaced Identify laterality – left, right Cervical Vertebra Identify type/site First cervical Stable burst Unstable burst Posterior arch Lateral mass fracture Second cervical Type II dens fracture Anterior displaced Posterior displaced Nondisplaced Other dens fracture Type III traumatic spondylolisthesis Other traumatic spondylolisthesis Third – Seventh vertebra Type III traumatic spondylolisthesis Other traumatic spondylolisthesis Unspecified spondylolisthesis fracture Identify fracture status Displaced Nondisplaced Identify Spinal cord injury Anterior cord syndrome Brown-Sequard syndrome Central cord syndrome Complete lesion of cord Concussion/edema Identify highest level of cervical spinal cord injury: C1-C8 Thoracic Vertebra Identify vertebral level First Second Third Fourth T5-T6 T7-T8 T9-T10 T11-T12 Identify type of fracture Stable burst Unstable burst Wedge compression 5 Lumbar Vertebra Identify vertebral level First Second Third Fourth Fifth Identify type of fracture Stable burst Unstable burst Wedge compression Sacrum Identify Zone Zone I: injuries are entirely lateral to the neuroforamina Zone II: injuries involve the neuroforamina but not the spinal canal Zone III: injuries extend into the spinal canal with primary or associated fracture lines Identify Type Type 1: transverse flexion fracture of sacrum without displacement Type 2: transverse flexion fracture of sacrum posterior displacement Type 3: transverse extension fracture of sacrum anterior displacement Type 4: transverse segmental communition of upper sacrum Identify fracture status Displaced Nondisplaced Sternum Identify site/type Manubrium Body of sternum Sternal manubrial dissociation Xiphoid process Ribs Identify type Single rib Multiple ribs Identify laterality – left, right, bilateral Skull Identify skull fracture site Vault of Skull Frontal bone Parietal bone Base of Skull Anterior fossa Ethmoid sinus Frontal sinus Middle fossa Occipital bone Orbital roof Posterior fossa Sphenoid bone Temporal bone 6 Identify nature of any intracranial injury Concussion Cerebral edema, which includes Diffuse edema Focal edema Contusion/laceration Brainstem Cerebellum Cerebrum Right cerebrum Left cerebrum Diffuse traumatic brain injury Focal traumatic brain injury Hemorrhage Intracranial Brainstem Cerebellum Cerebrum, left Cerebrum, right Epidural Subarachnoid Subdural Other specified intracranial injury Identify loss of consciousness No loss of consciousness 30 minutes or less 31 minutes to 59 minutes 1 hour to 5 hours 59 minutes 6 hours to 24 hours Greater than 24 hours With return to pre-existing conscious level Without return to pre-existing conscious level Any duration with death prior to regaining consciousness Death due to brain injury Death due to other cause Identify Fracture as Closed or Open 7
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