What is the proper procedure for charting a knee assessment?

Proper Procedure for Charting a Knee Assessment

A comprehensive knee assessment should include documentation of patient history, physical examination findings, and imaging results following standardized clinical decision rules such as the Ottawa Knee Rule or Pittsburgh Decision Rule to guide appropriate management and imaging decisions. 1

Patient History Documentation

• Record age (particularly noting if patient is >55 years per Ottawa rules or >50 years or <12 years per Pittsburgh rules) 1
• Document mechanism of injury (fall, twisting injury, direct trauma, motor vehicle accident) 1, 2
• Note onset, duration, location, and quality of pain 2
• Document ability to bear weight immediately after injury and in the examination room (ability to take 4 steps) 1
• Record presence of mechanical symptoms (locking, catching, giving way) 3, 2
• Note any history of swelling 2
• Document relevant medical history including previous knee injuries or surgeries 1, 2

Physical Examination Documentation

• Always examine and document findings from the uninjured knee first for comparison 3
• Record vital signs (particularly important if infection is suspected) 1
• Document inspection findings: deformity, swelling, ecchymosis, erythema 1
• Record palpation findings: joint line tenderness (medial/lateral), patellar tenderness, fibular head tenderness 1, 4
• Document range of motion measurements: ability to flex to 90 degrees (Ottawa criterion), active and passive range 1, 4
• Record stability testing results with specific tests:
  • Valgus/varus stress tests for collateral ligament integrity 3, 4
  • Lachman test and pivot shift test for anterior cruciate ligament 3, 4
  • Posterior drawer test and tibial sag test for posterior cruciate ligament 3, 4
  • McMurray test, bounce test, and Apley's grind test for meniscal injury 3, 4
• Document neurovascular status: pulses, sensation, motor function 2

Imaging Documentation

• Record decision-making process for ordering radiographs based on Ottawa or Pittsburgh criteria 1
• For radiographs, document:
  • Views obtained (minimum anteroposterior and lateral; additional patellofemoral view for suspected patellar fracture/dislocation) 1
  • Presence of fractures, dislocations, effusions, or other abnormalities 1
• For advanced imaging (if applicable), document:
  • Clinical indication for MRI (persistent pain, suspected internal derangement) 1
  • Indication for CT (suspected occult fracture) 1
  • Indication for vascular studies (CTA/MRA) in cases of knee dislocation 1

Assessment and Plan Documentation

• Clearly state the diagnosis or differential diagnoses 5, 2
• Document severity using a standardized rating system when applicable 5
• Record treatment plan including:
  • Immediate interventions (immobilization, weight-bearing status) 1, 2
  • Medication recommendations 2
  • Referral decisions (orthopedic, physical therapy) 6, 2
  • Follow-up timeline 2

Common Pitfalls to Avoid

• Failing to document Ottawa or Pittsburgh criteria findings when deciding whether to order radiographs 1, 6
• Omitting documentation of ability to bear weight, which is a critical criterion 1
• Incomplete documentation of special tests performed and their results 4, 5
• Ordering unnecessary imaging when clinical decision rules suggest they are not indicated 6
• Not documenting both positive and negative key findings that support your clinical decision-making 4, 2