Clinical focus: Documentation of wounds and injuries is a clinical, communication and medico-legal skill. A good record allows another clinician to understand what happened, reproduce your examination, continue treatment and assess evidence without guessing. Record observations separately from history and opinion, use precise measurements, preserve originals and state limitations honestly.
Learning objectives
- Write a contemporaneous, objective, complete wound record using a reproducible structure.
- Describe location, size, shape, orientation, margins, tissue, contamination, function and neurovascular findings precisely.
- Use body diagrams, photographs, imaging and specimen logs safely and lawfully.
- Distinguish fact, patient report, interpretation and expert opinion.
- Document consent, refusals, safeguarding, chain of custody, treatment and follow-up.
1. The principles of defensible documentation
| Principle | Meaning in practice |
|---|---|
| Contemporaneous | Record as soon as possible; include date/time and who was present. If delayed, state when and why. |
| Accurate | Measure and describe what is seen or reliably reported; do not guess depth, age, weapon or intent. |
| Complete | Include relevant positive and negative findings, treatment, consent, investigations, referrals and follow-up. |
| Objective | Use neutral language and separate the patient’s account from examination findings and interpretation. |
| Legible/secure | Use approved forms, secure electronic records, clear units and controlled access. |
| Transparent | Correct errors with a dated, signed amendment; never erase, backdate or silently overwrite. |
| Reproducible | Another clinician should be able to locate the injury, repeat measurements and understand change over time. |
2. The four-layer note
- History: what the patient or witness says, ideally in quotation marks for key phrases. Label the source and avoid leading questions.
- Examination: your observed findings, measurements, vital signs, function and relevant normal findings.
- Interpretation: clinical reasoning, differential diagnosis and limitations, clearly identified as opinion.
- Plan: treatment, investigations, consultation, safeguarding, evidence handling, discharge advice and follow-up.
Example: History: “I was cut by a knife during an argument.” Examination: “2.5-cm linear wound, left volar forearm, 4 cm proximal to wrist crease; brisk venous ooze; reduced sensation in ulnar distribution; radial pulse palpable.” Interpretation: “Possible sharp-force injury with suspected ulnar-nerve involvement; urgent hand review.”
3. Patient and encounter identifiers
- Full name, date of birth/age, hospital number, sex/gender as relevant, address/contact and emergency contact according to policy.
- Date, exact time and place of examination; referral source; arrival mode; accompanying persons.
- Examiner name, designation, registration/department, chaperone and interpreter details.
- Consent for examination, photographs, specimens, record release and police/safeguarding referral; document refusals and capacity assessment.
- Allergies, medicines (especially anticoagulants), immunisation/tetanus status, pregnancy possibility and relevant comorbidity.
4. History documentation
Mechanism and timeline
Record the patient’s account using their words, then clarify only what affects care: date/time, location, object or surface, direction, force, number of impacts, bleeding, loss of consciousness, first aid, washing/changes of clothing, contamination, animal/human bite, chemical/electrical exposure and symptoms since injury.
Symptoms and function
Document pain score and character, bleeding, swelling, numbness, weakness, reduced range of motion, foreign-body sensation, fever, breathing/swallowing difficulty, urinary/bowel symptoms and mental-health distress.
Reliability and limitations
Record the source, interpreter use, language, memory gaps, intoxication, sedation, cognitive impairment or contradictory information neutrally. Do not label a patient “unreliable” because their trauma memory is fragmented; state the specific limitation.
5. Wound-description template
| Field | What to record | Example |
|---|---|---|
| Number/label | Number wounds and use the same labels in text, diagram and photograph. | “Injury 1” and “Injury 2.” |
| Site/side | Region, side and fixed anatomical landmarks; record body position. | “Right lateral thigh, 8 cm above the knee joint line.” |
| Size | Length × width × visible depth in mm/cm; state whether wound is open or measured after approximation. | “3.0 × 0.8 cm; depth not probed due to possible tendon injury.” |
| Shape/orientation | Linear, curved, stellate, irregular, patterned; transverse/oblique/longitudinal. | “Curved, oblique, long axis inferomedial.” |
| Margins/ends | Sharp/blunt, abraded, contused, everted/inverted, tissue bridges, tails or angles. | “Irregular contused margins with tissue bridges.” |
| Base/depth | Skin/subcutis/fat/fascia/muscle/tendon/nerve/vessel/bone visible; foreign material. | “Subcutaneous fat visible; no exposed tendon; foreign body not seen.” |
| Colour/associated change | Redness, bruising, swelling, blister, eschar, discharge, necrosis; measure surrounding erythema. | “2-cm surrounding ecchymosis; no pus or cellulitis.” |
| Bleeding | Active arterial/venous/oozing, haemostasis method and response. | “Oozing stopped after 5 minutes direct pressure.” |
| Pain/function | Tenderness, movement, strength, sensation, pulses and capillary refill. | “Finger extension limited by pain; sensation and radial pulse intact.” |
| Photograph/diagram | File/figure number, scale, orientation and consent. | “Photo 1A overall, 1B close-up with scale.” |
6. Documenting specific injuries
Abrasions
Record superficial versus deep abrasion, site, dimensions, direction/pattern, crust, embedded debris and tenderness. Describe road rash or patterned impressions without claiming a unique surface unless compared by a qualified forensic examiner.
Contusions and haematomas
Measure maximum dimensions, site, shape, colour and swelling. State that bruise colour cannot reliably establish exact age. Record anticoagulants, bleeding disorders, skin tone, platelet abnormalities and alternative causes where clinically relevant.
Lacerations
Record irregular/contused margins, tissue bridges, depth, contamination, devitalised tissue and underlying structure function. Do not call every irregular wound “blunt force” without considering surgical wounds, animal bites and other causes.
Sharp, puncture and firearm wounds
Number entry/exit wounds, record dimensions, shape, margins, soot/stippling/foreign material where relevant and possible trajectory only as a cautious interpretation. Do not probe a deep wound or infer a specific weapon from a single wound.
Burns
Record agent if known, depth, total body surface area method, location, circumferential involvement, airway signs, ocular injury, pain/sensation and associated trauma. Photograph with consent and preserve clothing/evidence according to protocol.
Bites
Record human/animal source if known, site, dimensions, tooth/pressure pattern, bruising, puncture, tissue loss, contamination, neurovascular/tendon/joint function, tetanus and rabies risk. The appearance alone rarely identifies an individual.
7. Neurovascular and functional documentation
Write the actual findings, not “NVI” alone. Include time and comparison side.
- Vascular: colour, temperature, capillary refill in seconds, pulses (named and graded), Doppler, bleeding and perfusion.
- Motor: each relevant tendon/nerve action, strength grade, active/passive range and pain limitation.
- Sensory: light touch/two-point discrimination or named nerve territory; map numbness.
- Compartment: pain at rest/passive stretch, firmness, swelling, paresthesia and weakness; record serial examinations.
- Post-intervention: repeat after anaesthetic, reduction, splint, dressing, tourniquet or closure and document who was informed.
8. Body diagrams and injury mapping
Use a standard front/back/anatomical diagram. Mark the same injury number as the text and photograph. Include orientation (patient’s right/left, anterior/posterior), measurements, arrows or legend, date/time and examiner initials. Do not draw an injury to scale unless the form specifies it; never use a diagram instead of a written description.
9. Clinical photography
Consent and preparation
- Explain purpose, storage, access, possible legal release and the right to decline. Obtain separate consent for intimate images.
- Use a secure approved device; disable automatic cloud upload and personal messaging. Follow institutional information-governance policy.
- Take overall, mid-range and close-up views; include an identifying label and a measurement scale for close-ups without covering the injury.
- Use consistent lighting, focus and perpendicular angle; avoid filters, editing or beauty modes.
Photo log
| Field | Example |
|---|---|
| Image/figure number | “Photo 2B.” |
| Subject/site | “Left lateral forearm, injury 2.” |
| Date/time/photographer | “26 Sept 2026, 14:20, J. A., clinical officer.” |
| View/scale | “Close-up, 15-cm ruler in same plane.” |
| Consent/storage | “Consent documented; uploaded to secure record ID …” |
10. Imaging and laboratory records
- Record the indication, modality, body region, date/time, contrast, report and your interpretation separately. Preserve the official report and images in the approved system.
- For suspected fracture, foreign body, deep penetration or vascular injury, document why imaging was requested and how it changed management.
- Record specimen type, collection site, collection time, collector, container, laboratory accession, result, reference range and action taken.
- For forensic specimens, use a separate exhibit number and chain-of-custody log; do not mix clinical samples and legal exhibits.
11. Consent, refusal and capacity
Document information given, questions answered, capacity, voluntary choice and the exact part accepted or declined. Examples: “Patient consented to examination and treatment but declined photographs and forensic swabs”; “Patient requested a pause at 14:32; examination resumed at 14:45”; “Emergency haemorrhage control proceeded because delay threatened life; consent revisited once stable.”
12. Treatment and follow-up record
| Document | Details |
|---|---|
| Haemostasis | Pressure, packing, tourniquet time, haemostatic dressing, response and distal neurovascular status. |
| Analgesia/anaesthesia | Drug, concentration, dose, route, time, allergies, response and adverse effects. |
| Irrigation/debridement | Solution, approximate volume, debris/devitalised tissue removed, foreign body findings and tolerance. |
| Closure | Technique, suture/staple/adhesive type and number, tension, dressing, operator and follow-up removal plan. |
| Tetanus/antibiotic | Indication, product, dose, route, time, allergy review and planned duration. |
| Referrals | Specialist contacted, time, advice, transport and escalation instructions. |
| Discharge | Wound care, danger signs, safe contact, review date and patient understanding. |
13. Chain of custody and correction of records
For each specimen or item, record unique identifier, collection time/site, collector, seal, storage, every transfer and receipt. If a seal breaks or a delay occurs, record it honestly and notify the responsible supervisor.
Correct a paper error with a single line through the original so it remains readable, then add date, time, initials and reason. In an electronic record, use the approved amendment/audit function. Never delete, backdate, copy-forward incorrect information or create a second “clean” version.
14. Objective language: preferred and unsafe wording
| Avoid | Prefer |
|---|---|
| “Bad wound,” “minor injury” | Measured size, depth, tissue involvement, bleeding and functional effect. |
| “Fresh bruise,” “three-day-old bruise” | Colour, dimensions, tenderness and statement that exact age cannot be determined clinically. |
| “Patient is lying” | “History differs from earlier account in these specific details”; record source and context. |
| “Rape confirmed” | “Findings are consistent/compatible with the reported event; limitations stated.” |
| “Knife wound” | “Sharp-force-type wound” unless a qualified examination establishes more. |
| “No injuries” | List the regions examined and relevant normal findings; state any areas not examined. |
15. Safeguarding and medico-legal reporting
- Record concerns about child abuse, elder abuse, intimate-partner violence, trafficking, neglect or immediate danger, and follow current Ugandan reporting policy.
- Explain confidentiality limits and obtain consent for referral unless a lawful safeguarding exception applies.
- Do not contact or confront an alleged perpetrator. Do not give the patient a record that could increase danger if discovered.
- Use objective documentation, preserve originals and disclose the minimum necessary information through the lawful channel.
16. A complete sample note
History: “Patient states, ‘I fell onto broken glass at 10:00 today.’ Denies loss of consciousness. Tetanus status unknown.”
Examination: “At 10:35, alert, GCS 15, pulse 96, BP 118/74. Injury 1: 3.2 × 0.6 cm oblique laceration over the dorsal left hand, 2 cm proximal to the third MCP joint. Irregular contused margins, subcutaneous fat visible, no foreign body seen. Active bleeding stopped with direct pressure. Active finger extension and flexion intact; capillary refill <2 s; radial/ulnar pulses palpable; sensation intact in median/ulnar/radial territories. No tendon or joint exposure seen. Photograph 1A overall and 1B close-up with scale taken after consent.”
Assessment/plan: “Open hand laceration; occult foreign body and tendon injury considered. Irrigated with sterile saline after haemostasis, radiograph requested, tetanus assessed, analgesia given. Hand surgery contacted at 11:00; review arranged. Patient advised to return for bleeding, numbness, increasing pain, swelling, fever or reduced movement.”
17. Worked cases
Case 1: Documentation after assault
Record the survivor’s account in quotation marks, then separate examination findings, photographs, specimens, treatment and safety plan. Document normal findings and any declined procedure. Do not write “assault proved” or infer consent.
Case 2: Copy-forward error
A note copied from the prior day says “right leg wound,” but today the injury is left leg. Correct the record using the audit function, explain the error and notify the team; never silently overwrite it.
Case 3: Tourniquet
Record time applied, location, indication, bleeding response, distal neurovascular findings, reassessments and time removed. This is essential for clinical safety and later review.
18. Quick self-test
- What four layers should a wound note contain?
- Which measurements should every open wound description include?
- Why is “no injuries” unsafe documentation?
- What should be recorded after a splint or tourniquet?
- How is a paper error corrected?
Answers
- History, examination, interpretation and plan.
- Site/side with landmarks, length/width/visible depth, shape/orientation, margins/base, tissue/foreign body, bleeding, function and neurovascular status.
- It does not show which areas were examined or whether relevant normal findings were present; it may wrongly imply a complete normal examination.
- Time, indication, technique, response and repeat distal neurovascular findings.
- Single line through the original so it remains readable, then date/time, initials and reason; use the electronic audit/amendment function.
Key take-home points
- Write what was reported, what you observed, what you think and what you did—separately.
- Measure and map every injury; document function and neurovascular status before and after intervention.
- Use consented, secure, unedited photographs with scale and a photo log.
- State relevant normal findings and limitations; absence of a documented finding is not proof of absence.
- Maintain chain of custody and transparent audit trails; never backdate, delete or silently alter a record.
References and further reading
- WHO: Improving care of the injured
- MSD Manual Professional: Skin lacerations
- MSD Manual Professional: Approach to the trauma patient
- WHO: Guidelines for medico-legal care for victims of sexual violence
Educational note: Follow current Ugandan medical-record, forensic, privacy and safeguarding requirements. This lesson is educational and not legal advice.
