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.