Authors: Charlotte Elliott, Aaron Borbora / Editors: Mark Buchanan, Paul Johnson, Lauren Fraser / Reviewer: Charlotte Elliott / Codes: / Published: 21/11/2019 / Reviewed: 05/12/2024
Every year thousands of people present to the Emergency Department (ED) with a soft tissue injury.
Despite this, the literature suggests that doctors are lacking knowledge to correctly identify, describe and document injuries in the patients’ clinical notes.
Patients’ clinical notes, with documentation of their injuries, may have enormous medico-legal importance, especially in cases of alleged assault. It is therefore imperative that records are complete and accurate for use in any subsequent criminal or civil court proceedings that may arise.
For an injury description to be helpful it must be accurate. Better note keeping will ensure medical records and police reports are of better standard, helpful to the courts, and useful to doctors required to give evidence using this material.
This module aims to provide the learner with an overview of common types of skin and soft tissue injuries, how best to accurately describe these, and considers the mechanism most likely to be responsible.
Learning objectives:
- Be able to confidently describe a soft tissue and skin injury
- Be able to suggest what may have cause the soft tissue or skin injury
- Be able to describe soft tissue and skin injuries accurately in clinical notes.
References
- Bourne CL, Jenkins MA, Brewer KL. Estimation of laceration length by emergency department personnel. West J Emerg Med. 2014 Nov;15(7):889-91.
- Forensic Medicine. (2015) Wound Documentation. [Accessed 1 Jul. 2019].
- General Medical Council. Good Medical Practice. 2024. [Accessed 17th Nov 2024].
- Machin V. Churchills Medicolegal Pocketbook. Edinburgh: Churchill Livingstone. 2023.
- Royal College of Emergency Medicine. Information sharing to tackle violence , ISTV Standard Operating Procedure (SOP) [online]. March 2024.
- Peterson N, Stevenson H, Sahni V. Size matters: how accurate is clinical estimation of traumatic wound size? Injury. 2014 Jan;45(1):232-6.
- Wyatt J, Squires T, et al. Oxford Handbook of Forensic Medicine. New York: Oxford University Press. 2011.
