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Xray Documentation

 

Xray Documentation ICD-10

Location: Right / Left; name of bone; specific location on bone (shaft, neck, base, condyle etc)
. Fracture pattern: transverse, oblique, spiral, comminuted, segmental, longitudinal, greenstick.  
Alignment: displaced or nondisplaced
. Result: routine healing, delayed healing, malunion, or nonunion.  
Classification:

LEO C. FAR traumatic fracture documentation
L Location and Laterality 


  • Right / Left; name of bone; specific location on bone (shaft, neck, base, condyle etc)

E Encounter

  • 
Initial or subsequent encounter

O Open or Closed

  • 
open or closed.

C Classification, Category, or Cause


  • open traumatic fracture = Gustilo classification of the fracture.
  • 
Physeal fracture = Salter-Harris classification.

  • Proximal Humerus = modified Neer classification

F Fracture pattern


  • Fracture pattern: transverse, oblique, spiral, comminuted, segmental, longitudinal, greenstick

A Alignment


  • displaced or nondisplaced

R Result


  • Routine healing, delayed healing, malunion, or nonunion 

Reference: Margaret M. Maley, BSN, MS, AAOS Now Nov 2013