Injuries

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Injuries

Progression

  • When did disease process start
  • Initial versus subsequent visit

Location

  • Anatomical location-right, left, upper quadrant or lower quadrant, distal or proximal, etc.

Acuity

  • N/A

Name

  • Injury type-abrasion, contusion, crush injury, fracture, strain concussion with or without loss of consciousness along with time, etc.

  • Site and laterality, when appropriate

  • Sequela-late effect such as complications or conditions that arise as a direct result of an injury

Necessary Procedures

  • As indicated

Other

  • Brain compression, cerebral edema
  • Presence and type of shock-hypovolemic, cardiogenic, septic
  • Presence of open wound into cavity

Why

  • Suicide attempt