Documentation Tips

When describing open wounds in the emergency department, there are some important historical key points that need to be considered:

• Mechanism of injury
• Type of injury: blunt trauma, sharp force trauma, or both
• Area of the body injured
• Object causing injury: type, size, other characteristics (ie, clean or contaminated)
• Social factors: consistency of wounds or injuries seen with the history provided

After obtaining a thorough history, each wound should be closely inspected and documented. The more precise the wound description, the clearer it will be to future chart readers. Wound descriptions should include the precise location, relationship to key body landmarks, size, shape, directionality, patterned appearance, and any other unique characteristics. The presence of any debris, bleeding, or foreign matter should be noted.

When documenting the size of a wound, a ruler or other measurement device should be used. Most cotton tip applicator packages have a ruler imprinted on the packaging. Whenever possible, at least two measurements should be documented, length and width, length and depth, or all three. Some implements used for stab wounds have unique characteristic patterns that can be imparted into the skin surface. Any of these hallmark patterned wounds should be described. Forensic experts may be able to match the wound pattern to the weapon that caused it.

Wounds should be documented using both narrative descriptions and graphic representations using electronic medical record (EMR)–embedded body diagrams and/or uploaded digital photographs of the patient’s injuries. EMR-embedded body diagrams are often used to highlight wound location and shape but may make accurate wound representation difficult compared to written charts. Digital photographs, on the other hand, provide an accurate representation of the wound and memorialize findings for future review by other clinicians and experts, plus they may be useful in any potential legal proceedings. Most current EMRs allow images to be uploaded securely, creating easy storage and access.

Case Resolution

Based on your examination, you feel the wound is consistent with a laceration, although the mechanism is uncertain. The patient’s wife later arrives and states he was walking down the patio steps when he stumbled, struck his toe against the edge of the step, cried out in pain, and began bleeding. The wound is irrigated, and its characteristics are documented. The wound is sutured, and the patient is discharged with return precautions and follow-up instructions for suture removal.

Dr. Riviello is chair and professor of emergency medicine at the University of Texas Health Science Center at San Antonio.

Dr. Rozzi is an emergency physician, director of the Forensic Examiner Team at WellSpan York Hospital in York, Pennsylvania, and chair of the Forensic Section of ACEP.