Enhancing Safe Orthopedic Rehabilitation: Evaluating Documentation Practices for Mobilization and Weight-Bearing Protocols

Background Accurate documentation of mobilization and weight-bearing status is critical for safe rehabilitation following orthopedic surgery or musculoskeletal injury. Poor or inconsistent recording can lead to miscommunication between teams, inappropriate rehabilitation prescriptions, and adverse patient outcomes. In August 2024, the British Orthopaedic Association (BOA) introduced updated standards to standardize terminology and enhance clarity across multidisciplinary teams. By auditing current practice against these BOA standards, this study identifies gaps in documentation and proposes targeted interventions to promote consistency, improve patient safety, and strengthen multidisciplinary care. This audit was conducted at a major trauma center in the UK. Objectives The objectives of this study are to evaluate compliance with BOA standards in documenting weight-bearing status and mobilization plans for orthopedic patients and to implement targeted educational interventions aimed at improving documentation practices, with their effectiveness assessed in a subsequent audit cycle. Methods A retrospective audit was conducted on 248 patients aged ≥16 years with operative or nonoperative orthopedic conditions affecting the pelvis, upper limbs, or lower limbs. Patients with spinal injuries or aged <16 years were excluded. Documentation was assessed against BOA criteria, including terminology use, clinical justification, quantification of limitations, duration of status, and rehabilitation protocols. Data were analyzed descriptively to determine compliance rates across documentation domains. Results are presented as proportions with 95% CIs. Results Of the 248 cases, only 95 (38.3%, 95% CI: 32.2-44.7) used standard BOA terminology: seven cases (3.0%, 95% CI: 1.2-6.0) documented "Unrestricted Weightbearing", 30 cases (12%, 95% CI: 8.4-16.8) used "Limited Weightbearing" (LWB), and 58 cases (23%, 95% CI: 18.4-29.1) recorded "Non Weightbearing" (NWB). The remaining 153 cases (62%) used non-standard terms, with "Full Weightbearing" (FWB) being the most frequent at 104 cases (42%, 95% CI: 35.8-48.2). Out of the 248 cases audited, 119 patients (48%) required documentation to justify either NWB or LWB status. Among these, clinical justification was provided in 77 cases (65%), while 42 cases (35%) lacked appropriate documentation (95% CI: 57.0-72.5%). Quantification of LWB limitations was documented in 52 cases (68%), with 24 cases (32%) missing this detail (95% CI: 60.0-76.0%). From the total 248 cases, 118 patients required documentation specifying the duration of their NWB status. Of these, duration was recorded in 109 cases (92%), while nine cases (8%) lacked this information (95% CI: 87.0-96.5%). Additionally, among the 53 cases where documentation of walking aids and rehabilitation protocols was required, this information was recorded in 51 cases (96%) and absent in two cases (4%, 95% CI: 92.0-99.0%). Conclusions Initial compliance with BOA documentation standards was suboptimal, particularly regarding terminology and justification for restricted weight-bearing. Statistically significant gaps were identified across multiple domains. Targeted education and visual prompts may enhance documentation consistency and promote safer rehabilitation planning.