Definition

While the terms wound and injury maybe used interchangeably, this can be incorrect, as a wound involves a break in the skin.

Documentation of an injury should meet the criteria as described in Churchills’ Medicolegal Pocketbook:

  • Documentation of where and when examination took place.
  • Accurate documentation of the type of injury (laceration, abrasion, incision, etc) – does this match the alleged mechanism of injury?
  • Documentation of the shape of the injury, its location and measurement from a fixed anatomical point. Diagrams can be employed here.
  • Documentation of colour.
  • Documentation of the presence or absence of active bleeding or clot.
  • Whether it appears to be showing signs of healing.
  • Documentation of what treatment, if any, was given.

Further, if a patient presents with an injury, it is important to consider how this information may be shared and used. Information Sharing to Tackle Violence (ISTV) is a national programme that seeks to use information collected from patients presenting the Emergency Department with an injury to prevent further violence and injury. By knowing where and how people are injured to up one third of injuries can be prevented. One third of people treated for injuries in ED do not tell the police.

Anonymised data captured in ED is shared with the Community Safety Partnership team. Together with policing and local authority data is can be used to work out areas of antisocial behaviour and mechanisms put in place to address this.

They recommend the following questions are asked and recorded:

  • Date and time of injury
  • Place (the physical location of where the injury happened NOT the anatomical location of the injury)
  • Injury intent (why it happened)
  • Injury activity status and type (what was the injured person doing at the time of the event eg in a restaurant, at home, at work etc)
  • Injury mechanism (physical cause of the injury)
  • Drug or alcohol involvement
  • Assault location description (a more detailed description of where specifically the assault took place)

In cities where ISTV data is recorded well, shared, and used, serious violence decreased by 30-40% compared with cities where this information is not shared.

Do not forget to consider safeguarding concerns and referral if warranted.

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