Describe the patient's injuries

When a patient suffers a trauma that results in injuries, you need to record all the injuries, how and where they occurred, and any other relevant details.

  1. At the top of the page, click the Narrative tab.

    The contents of the Narrative tab appear, set to the Impressions bookmark in the left pane.

  2. In the left pane, click the Injuries bookmark.

    The right pane scrolls down to the top of the Injuries section of the page.

  3. For Possible Patient Injury, choose one of Yes, No, or Unknown.

    If you choose Yes or Unknown, the Primary Injury, Mechanism of Injury, Place of Injury, and Date of Injury fields activate.

  4. For Primary Injury, click the field or the list icon to the right of the field, then select the appropriate single option from the menu that appears to choose the category of the reported/suspected external cause of the injury.

    Example: Burns

    The Injury Details field activates.

  5. For Injury Details, click the field or the list icon to the right of the field, then select the appropriate single option from the menu that appears to indicate the mechanism of the event which caused the injury.

    Example: Hot metals contact

    The Additional Injuries field activates.

  6. For Additional Injuries, click the list icon to the right of the field, select all the appropriate options from the menu that appears, then click OK or click outside the menu to list any other injuries the patient has suffered, that are not included in the primary injury.

  7. For Mechanism of Injury, click the list icon to the right of the field, select all the appropriate options from the menu that appears, then click OK or click outside the menu to identify the mechanism of the event which caused the injury.

    Example: Blunt, burn, penetrating

  8. For Place of Injury, click the field or the list icon to the right of the field, then select the appropriate single option from the menu that appears to chose the geographical location where injury occurred.

    Example: Farm, home

  9. For Date of Injury, click the calendar icon on the right end of the field and select the appropriate date from the calendar that appears to specify the data of the patient's injury.