1. Fracture care documentation requires 3 components – confirmation, stabilization and follow-up.
a. Confirmation - There should be a radiological confirmation of the fracture. This can be easily documented under the radiology interpretation section of your T-sheet. Be sure to specify the location and type of fracture.
b. Stabilization – With fracture care you should outline your treatment plan, which includes pain meds, local treatment and stabilization when applicable. When stabilizing a fracture you must document who placed the immobilization device (yourself, tech or nurse) as well as document the post splint placement neurovascular status. Your T-sheet has a splinting template available on the backside of most of the injury templates. This section should be completed for all splinted fractures.
c. Discharge Follow-up - One of the requirements of fracture care is to specify the fracture follow-up treatment timeline. It must be clear as to when the follow-up should occur. We must eliminate any possibility that the patient is to be seen imminently (24 hours or less) by the specialist. You must specify when the patient should follow-up with their PCP or Ortho i.e. – “2-3 days” or “4-5 days”, etc. This can be documented directly on the template or in the discharge instructions.