How to describe this injury in documentation

Nurses General Nursing

Published

Hi Nurses,

I have a question...

How would you document professionally this type of injury: 11mm circular "hole" that went all the way through the skin layers, located underneath the mouth on the right side of the face...

I might not be describing it correctly for you guys to imagine it...but basically the person fell and some kind of tool punctured a circular hole underneath the right side of the mouth...so there was a hole outside on his face...and inside his mouth...

Don't worry, this is not how I documented...

Thanks for any input.

Specializes in Advanced Practice, surgery.

I guess some thing like "Penetrating injury, 11mm circular wound. Right side of face (I'd be a bit more descriptive of where though) Full thickness through skin into oral cavity"

Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

That's where a good old Polaroid camera with the grid on the lens would have helped. They quit making them though. Wonder if any digital camera maker has thought of it? Before computer charting I drew many a thing in the chart that was hard to describe.

Thank you for your comments!! Feel very good about yourselves for helping a new nurse out...haha :) Seriously, thank you very much for your time!!

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