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Orthopaedics

Musculoskeletal and orthopaedic clinical documentation.

Documentation Overview

Orthopaedic documentation requires precise anatomical description, functional assessment and accurate recording of imaging findings. Trauma documentation must follow specific protocols for medico-legal and audit purposes.

Key Documentation Standards

  • Precise anatomical description of injuries and pathology
  • Neurovascular status documented on admission and post-operatively
  • Mechanism of injury documented for trauma patients
  • Radiological findings described in clinical notes
  • Physiotherapy and rehabilitation goals documented
  • VTE risk particularly high — document prophylaxis clearly

Common Documentation Scenarios

  • Fractured neck of femur — admission, surgical checklist, post-op mobilisation
  • Elective joint replacement — pre-op assessment, consent, discharge with physio plan
  • Acute soft tissue injury — mechanism, examination, imaging, management
  • Spinal assessment — neurological examination documentation
  • Paediatric trauma — growth plate consideration documented
  • Revision surgery — previous operative details and indication

Relevant Templates

Quick Reference
ORTHOPAEDIC DOCUMENTATION CHECKLIST
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TRAUMA CLERKING
□ Mechanism of injury
□ Time of injury
□ Neurovascular status distal
□ Open / closed injury
□ Associated injuries
□ Pre-injury function

EXAMINATION DOCUMENTATION
□ Deformity / swelling / bruising
□ Tenderness location (precise)
□ Range of movement
□ Neurovascular: pulse, sensation, motor
□ Compartment syndrome excluded

FRACTURE DESCRIPTION
□ Bone and site
□ Pattern (transverse/oblique/spiral)
□ Displacement
□ Angulation
□ Intra/extra articular
□ Open or closed

POST-OPERATIVE
□ Neurovascular status checked
□ Wound status
□ Drain output
□ Mobilisation plan
□ Weight-bearing status
Specialty-specific: Always refer to your hospital's specialty-specific documentation policies and national guidelines.