Examination Documentation

For Medical Students

What It Tests

The record is what the examination becomes. Everything else is gone the moment the patient leaves the room.

A usable record has one property: another clinician can repeat the examination and say whether the knee has changed. That is a higher standard than describing what was found.

Most knee examination records fail that test, and the reason is almost always the same. They record conclusions rather than observations.

How It Is Performed

Record what you looked at as well as what you found, because a normal finding is only informative if the reader knows it was sought.

Record the effusion, the range in degrees, and the extensor mechanism on every knee, because all three change and all three matter. 4.7.4 covers flexion.

Record laxity as a comparison with the other side, with an endpoint, and with the flexion angle the test was done at.

Record negatives explicitly where they matter. The hip was examined and was normal is worth writing; silence about the hip is not.

And record what the patient said they cannot do, in their words, because that is the outcome everything will be measured against.

What a Positive Means

A finding recorded without its conditions cannot be compared later, which means it was almost not worth recording.

Grade two laxity is not comparable with anything. A firm endpoint at thirty degrees with five millimetres more translation than the other side is.

Full range is not comparable. Zero to one hundred and thirty degrees with a soft end feel is.

A positive McMurray is not comparable. Pain and a palpable click at the medial joint line on the third attempt is. 4.9.3 covers the test.

MRCS Level

How It Is Performed

Four elements make a knee laxity record complete, and omitting any one of them makes the entry close to unusable.

The direction loaded, the flexion angle, the endpoint, and the comparison with the other side.

Rotation needs the same four, and rotation is where records are weakest. A dial test recorded without both flexion angles cannot distinguish an isolated posterolateral injury from a combined one, which is the whole point of the test. 4.13.4 covers it.

Effusion is recorded by the method used, because the methods differ in what they detect. A negative patellar tap and a negative sweep test are not the same claim. 4.8.5 covers the sweep.

How Good It Is

A well recorded examination outperforms a better examination that was recorded badly, which is an uncomfortable claim and holds in practice.

The reason is that single examinations rarely decide anything in the knee. A trajectory does, and a trajectory needs two comparable examinations.

An acute examination recorded with endpoints and angles becomes useful six weeks later. The same examination recorded as a grade becomes a number nobody can reinterpret.

Inter-observer agreement for knee laxity tests is moderate at best, and recording conditions is the main thing within a clinician's control that improves it. No figure is quoted here, under decision 023.

FRCS Level

How Good It Is

At decision level the record has a second job: it has to show the reasoning as well as the findings.

An entry that records findings and then a plan, with nothing between them, is unreviewable. What is missing is why those findings produced that plan.

That matters most where the decision was close. A knee reconstructed on a borderline rotational grade and a high functional demand is a defensible decision and only if the record says both things.

It matters again where the decision was to wait. A recorded decision to observe, with the reason and the review interval, is a clinical act. The same decision unrecorded looks like an omission.

4.22 covers the scored instruments, which do part of this job and not the reasoning part.

Where It Misleads

Records mislead in ways that are worth naming, because each has a specific remedy.

A conclusion recorded as a finding. Anterolateral rotatory instability is an interpretation; what the knee did is the finding. Record the second and the first can be revised.

A template that fills itself. A proforma with default normal values produces records that say an examination happened when it did not, and these are worse than a blank note because they are believed.

A copied forward entry. The previous examination duplicated into today's note destroys the trajectory that is the record's main value.

And a record written for one audience. An entry written to justify a decision reads differently from one written to describe a knee, and the second is what the next clinician needs. 4.1.7 covers the audiences.

Fellowship Level

Where It Misleads

In revision and referred practice the record is frequently the only evidence of what the knee was like before someone operated on it, and it is usually inadequate.

The commonest gap is a pre-operative examination with no rotational assessment, which makes it impossible to say afterwards whether a rotational complaint is new or was always there. 4.10.12 covers the consequence.

The second is range recorded without end feel, so a developing contracture cannot be dated. 4.7.5 covers end feel.

The third is an examination under anaesthetic recorded without saying it was under anaesthetic, which makes it non-comparable with everything before and after it.

The practical conclusion is that the pre-operative examination record is part of the operation. A reconstruction whose pre-operative rotational state was never recorded cannot be audited, and a procedure that cannot be audited cannot be improved.

This page's claims are standard teaching and no frequency is cited for any of them, which is the condition of the whole site and is stated on every page.