Internal Injury Documentation Guidelines

Transcription

1 Internal Injury Documentation Guidelines General Open Wound of Thorax Injury to Heart Identify episode of care Initial Subsequent Sequela Laterality Sequela of injury Place of occurrence of injury Activity of patient at time of injury Identify general region of open wound of thorax Front wall of thorax Right front wall Left front wall Unspecified side Unspecified part of thorax Back wall of thorax Right back wall Left back wall Unspecified side Identify penetration Without penetration into thoracic cavity With penetration into thoracic cavity Identify type of wound Puncture Bite Unspecified open wound Identify any associated injury Heart Other intrathoracic organs Rib fracture Spinal cord injury Spinal cord injury Traumatic hemothorax Traumatic hemopneumothorax Traumatic pneumothorax Identify presence or absence of hemopericardium Without hemopericardium With hemopericardium Mild (without penetration of heart chamber) 1

2 Moderate (with penetration of a single chamber) Major (with penetration of multiple heart chambers) Unspecified surgical neck fracture Injury to Lung, Bronchus, and/or Thoracic Trachea Injury to Pleura, Esophagus, Diaphragm Injury to Intrathoracic Blood Vessels Open Wound of Abdominal Wall Lung Bronchus Thoracic trachea Identify laterality Unilateral, bilateral Pleura Esophagus Diaphragm Other specified intrathoracic origin Lymphatic thoracic duct Thymus gland Artery Thoracic artery Vein Superior vena cava Innominate or subclavian vein Pulmonary blood vessels Other blood vessels Intercostal Other blood vessels which include Azygos vein Mammary artery/vein Identify injury Minor incomplete transection Major complete transection Identify general region of open wound of abdominal wall Right upper quadrant Left upper quadrant Epigastric region Right lower quadrant 2

3 Left lower quadrant Periumbilic region Identify penetration Without penetration into thoracic cavity With penetration into thoracic cavity Identify type of wound Puncture Bite Unspecified open wound Identify any associated injury to intra-abdominal organs Spleen Liver Gallbladder/bile duct Pancreas Stomach Intestine Colon Rectum Peritoneum Injury of Spleen Liver injury Minor (less than 2cm) Major (greater than 2cm) Unspecified Superficial, which includes Less than 1 cm Capsular Minor Moderate (1-3cm) Major which includes Greater than 3cm Avulsion of spleen Massive laceration Multiple moderate lacerations Stellate laceration Minor, which includes Less than 1 cm deep Capsule only Without significant involvement of hepatic parenchyma Moderate 3

4 Less than 10cm long and less than 3cm deep Parenchymal involvement but without major disruption of parenchyma Major which includes Greater than 10cm long and 3cm deep Multiple moderate lacerations Stellate laceration Injury of Gallbladder and Bile Duct Injury of Pancreas Injury of Stomach Injury of Small Intestine Injury of Colon Injury of Rectum Other injury Minor Moderate Major Identify region of pancreas Head Body Tail Identify part of small intestine Duodenum Other specified part of small intestine Identify part of colon Duodenum Other specified part of small intestine 4

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