Knee Assessment Guidelines

Patient History Documentation

• The American College of Radiology recommends recording age, particularly noting if patient is >55 years per Ottawa rules or >50 years or <12 years per Pittsburgh rules, to guide appropriate management and imaging decisions 2, 3
• Documenting the mechanism of injury, such as fall, twisting injury, direct trauma, or motor vehicle accident, is crucial for determining the need for imaging 2
• The ability to bear weight immediately after injury and in the examination room, such as taking 4 steps, should be documented to inform clinical decision-making 1, 2
• Relevant medical history, including previous knee injuries or surgeries, should be recorded to provide context for the current assessment 2

Physical Examination Documentation

• The American College of Radiology suggests recording vital signs, particularly if infection is suspected, to identify potential complications 2
• Inspection findings, such as deformity, swelling, ecchymosis, and erythema, should be documented to assess the severity of the injury 2, 4
• Palpation findings, including joint line tenderness, patellar tenderness, and fibular head tenderness, should be recorded to identify potential areas of injury 3
• Range of motion measurements, such as the ability to flex to 90 degrees, should be documented to assess knee function 3

Imaging Documentation

• The American College of Radiology recommends recording the decision-making process for ordering radiographs based on Ottawa or Pittsburgh criteria to ensure appropriate imaging 1, 2, 3
• For radiographs, the views obtained, such as anteroposterior and lateral, and the presence of fractures, dislocations, effusions, or other abnormalities should be documented 1, 2, 4
• Advanced imaging, such as MRI or CT, should be documented with a clear clinical indication, such as persistent pain or suspected internal derangement 5, 4

Assessment and Plan Documentation

• The treatment plan, including immediate interventions, such as immobilization and weight-bearing status, should be documented to ensure clear communication and follow-up 2

Common Pitfalls to Avoid

• Failing to document Ottawa or Pittsburgh criteria findings when deciding whether to order radiographs can lead to unnecessary imaging 1, 2
• Omitting documentation of the ability to bear weight can result in incomplete assessment and inappropriate management 1, 2