This document discusses different types of wounds, bruises, and the importance of precisely documenting them. It describes various wound types like lacerations, incisions, and stab wounds. It also outlines different types of bruises including petechiae, purpura, ecchymoses, and hematomas. The document stresses that accurate documentation of wounds and bruises is important for healthcare providers to effectively treat patients and communicate details to the medical team. It provides templates for documenting key details like location, dimensions, shape, surrounding tissue condition, and color.

1. Different Types Of
Wounds, Bruises And
Their Documentation
Precise documentation of
wounds and bruises is very
important for healthcare
providers to give quality
care and treatment to
patients.
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Wounds and bruises are common types of injuries that occur on
the skin. However, they vary greatly in causes, signs, and
symptoms.
Various Types of Wounds
➢ Lacerations – This is an irregular, jagged, tear-like wound
thatoccurs when the skin, tissue, and/or muscle is torn or
cut open. The wound may be deep or shallow, long or
short, and wide or narrow. It is often contaminated with
bacteria and debris from whatever object caused the cut.
➢ Incisions - This surgical wound results from a cut or
incision in the skin that is made during surgery. It is caused
by the sharp edge of a cutting instrument such as a knife or
tool or the sharp edge of broken glass.
➢ Stab Wounds - This wound is a penetrating trauma to the
skin, resulting from a knife or a similar pointed object that
is deeper than it is long on the skin surface.
In fact, large wounds or wounds with severe bleeding require
immediate medical attention, as blood loss can lead to falling
blood pressure as well as shock.

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Different Types of Bruises
Bruises are usually black or blue marks on the skin that appear
after a bump or injury.
➢ Petechiae- They are tiny, purple, red, or brown spots on the
skin that may be produced by mechanical trauma,
constriction of clothing, or suction. They usually appear on
the arms, legs, stomach, buttocks, inside the mouth or on
the eyelids.
➢ Purpura– These conditions are popularly known as blood
spots or skin hemorrhages, are a red or purple-colored spots
on the skin. They are often seen in the elderly who have an
increased hemorrhagic tendency.
➢ Ecchymoses – They are used to describe bruises that are
over one centimeter in diameter. They are usually
characterized by a reddish or bluish discoloration of the
skin that is often non-raised and spontaneously caused by a
medical condition.
➢ Hematoma – This bruise occurs when blood collects under
the skin surface.

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Documenting Wound and Bruises
Accurate and efficient wound care documentation communicates
information about the care healthcare providers give and the
status of the patient to the rest of the medical team. Based on
this, wound care practitioners can prepare a better treatment
plan, and improve patient care and outcomes. While
documenting wounds and bruises, the following templates must
be considered to produce a clear, concise and complete record.
• Anatomical position
• The dimensions of the wound
• Shape of the wound -- whether curved, linear, irregular or
straight
• Condition of nearby tissues
• Color of the injury should be noted, especially when
describing bruises
• Presence of foreign material in or around the wound
• Any characteristics of the edges of the wound
However, documentation of wounds and bruises using wound
care EHR helps reduce medical errors, enables safer and more
reliable prescribing, enhances privacy and security of patient

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data, helps providers improve their productivity and work-life
balance, enables providers to improve efficiency and meet their
business goals, and reduces the costs and time associated with
the paperwork.