A proper assessment of an injury includes the site, size, shape, orientation, margins, and wound type of the injury. Usually, these descriptions only apply to open wounds, not closed wounds.
The site describes the location of the injury (i.e., right lower lip, left bilateral extremities). The size is the length, width, and sometimes depth of an injury. These measurements are usually communicated in centimeters (cm) in healthcare settings. For example, an injury description for the measurement might read 1x5 cm. The shape of the injury would be described using words such as linear, crescent-shaped, or stellate. A linear wound typically has a straight shape that would be caused by items such as a knife, razor, or glass. A stellate wound shape typically has an irregular shape that would be caused by incidents such as blunt force trauma and sometimes falls. A crescent-shaped wound is in the shape of a crescent moon.
The orientation of an injury would be a description such as vertical, horizontal, or oblique. The margins would describe the wound itself. For example, it would state if the wound is a bruise or abrasion. It would also describe if the injury is regular, irregular, smooth, or rough. A bruise is a visual hemorrhage beneath the skin that is usually caused by blunt force trauma, such as a fall or being hit with an object. A abrasion is a scratch or graze to the skin causing open areas. The wound type describes the type of wound such as a laceration, abrasion, or open wound. An example of an injury description is as follows: 1x5 cm linear, horizontal laceration to the right great toe, smooth edges.