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.
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