Context

Thousands of patients present to the emergency department each year with skin and soft tissue injuries. It is not unusual, especially on a Friday or Saturday night, to see multiple types of injuries during a shift – the elderly lady who has fallen out of bed and hit her head, the teenager who has deliberately cut her wrist with a razor blade, the patient who alleges assault with a baseball bat the list goes on.

Correct descriptions of injuries are vital to ensure good record keeping, a core component of the GMC’s Good Medical Practice. Correct descriptions of injuries are also vital in cases of alleged assault where the notes form the basis of potential legal proceedings. When you are thrust your clinical notes several months after seeing the patient and asked to write a police report, it is likely you have forgotten the patient’s injuries and so have to rely on your notes. Incorrect descriptions may lead to professional embarrassment and potentially injustice for the victim.

You wouldn’t describe a wheeze as a crepitation so don’t describe an abrasion as a laceration.