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Surgery and internal fixation to ensure proper alignment of the growth plate and the joint surface What bone is fractured? What is the laterality? What event caused the injury? What site on

Date: 2/18/2017
Location: NICC Medical Center Emergency Department
Provider: Michele Grant, M.D.
Patient: Willie Munoz
Gender: M
Age: 8
Chief Complaint: pain, tenderness, swelling, and distortion on right knee after being tackled while playing football at school
Assessment: X-ray shows type III fracture of growth plate at the upper end of the tibia
Plan: Surgery and internal fixation to ensure proper alignment of the growth plate and the joint surface
What bone is fractured?
What is the laterality?
What event caused the injury?
What site on the bone is injured?
How are fractures to the growth plate classified?
What is they type (classification system level) of this fracture?
What are the symptoms?
Should the symptoms be coded? Why or why not?
What is the episode of care? ER, Inpatient or Observation?
What is the intent?
What is the location? (place of occurrence)
What is the external cause status?
What activity was he engaged in?

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