Stab Wounds – Characteristics and Documentation

Stab wounds are those wounds that penetrate with a depth greater than their length, and are caused by a large variety of objects. The depth depends upon several factors such as the amount of force delivered by the object, the victim’s movement, sharpness and shape of the object. Understanding the characteristics of the stab wounds and their proper documentation via wound EMR can help you provide appropriate treatment at the right time and enhance the wound healing process.

Important Characteristics of Stab Wounds

  • They have different appearances at the skin level depending upon the object that caused the wound. For example, a double edged blade may result in a wound with an elliptical shape.
  • They have clean cut edges with one or both ends pointed. The non-pointed end may be squared off or split.
  • Due to the elasticity of the skin tissues, stab wounds are often gaped.
  • The cross section of the object that caused the wound can be demonstrated when the edges of the wounds are opposed.
  • Underlying bones may be scored by the object and abrasions may be present.
  • There may be frequent notching or change in direction owing to the relative movement of the object and the body.

Though these characteristics may help you understand the wound better, it is not possible to measure the depth of a stab wound from its appearance. A thorough wound examination is required to measure the actual depth of the wound. The wound should be measured and documented again after the apposition of its edges (which may provide additional information regarding the wound). If the knife or blade entered the skin at an oblique angle, the length of the entry slit may be longer than you expect.

Crucial Documentation Elements

Document the details of the wound after thoroughly examining the wound. Instead of interpreting the appearance of the wound, you should simply describe what you saw during the examination. Here are the crucial elements of stab wound documentation.

  • Location – Stab wounds should be documented in terms of their anatomical position. You can further describe the location in relation with the fixed anatomical landmarks (for example, above the shoulder)
  • Size – The size comprises the length, width and depth of the wound.
  • Shape – This may be curved, linear, irregular, straight and so on.
  • Color – The color of the wound should be documented properly.
  • Edges – Describe any characteristics of the edges of the wound.
  • Surrounding Tissue – The condition of the nearby tissues should be documented.

You should document whether any foreign material is present in and around the wound. The use of wound photographs would supplement the medical notes.

Relevance of Wound EMR

General EMR is comprised of general templates that require a lot of time for wound care nurses and physicians to find wound-related fields to enter and access the wound details. Wound EMR on the other hand provides wound specific templates which allow wound care professionals to document multiple wounds quickly and effectively without spending time searching. The other major advantages are as follows.

  • The stab wound documentation should be updated throughout the healing process so that the wound care physician can give appropriate care at the right time. For example, immediate intervention from physician is required when the wound tissue appears yellow, white, or black in color. Promptly updated wound documentation would reflect the color change. With wound EMR, it is easy to update the documentation with wound specific templates. If the system is supported with a physician and nurse interface, it will further enhance the communication.
  • Wound EMR allows seamless import of wound images into the patient chart and provide better image management. The system has the ability to capture a digital image of a wound and draw on it while saving the original image.

Wound EMR supported on smart devices allows you to document all the details regarding the wounds at the bedside itself.