Assignment task:
Subjective: This is an 85 year old female that fell 5 days ago and injured her right wrist and hand. She fell on her outstretched hand. Pan is on the ulnar side of the wrist.
Objective: Elderly female in no apparent distress. Right wrist, no swelling, tender proximal 4th and 5th metacarpals. Full range of motion of the wrist. Several multiple joint deformities of the fingers from DJD.
X-ray shows fracture of the base of the 5th metacarpal with some angulation.
Patient placed in ulnar guttar splint and will follow up with orthepedics in 5 to 7 days.
Assessment: Closed fracture of 5th metacarpal of the right wrist.
Electronically signed by
Date seen:
Which of the 7 High-Quality clinical documentation criteria is not evident in the above example?