How to write injuries in different parts of the body describe
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Use a systematic, factual, head-to-toe format. Do not write conclusions such as “assault injury” unless confirmed. Record what you actually see, what the person says, and your examination findings separately.
For every injury, include:
- Site: exact anatomical location and side
- Type: abrasion, bruise/contusion, laceration, incision, puncture/stab wound, swelling, burn, deformity
- Size: length × width × depth in cm, if applicable
- Shape and margins: linear, curved, irregular; clean or ragged edges
- Colour and surrounding area: red, blue-purple, brown, swollen, tender, bleeding
- Direction/pattern: for example, “linear abrasion running downward and medially”
- Associated findings: pain, tenderness, reduced movement, numbness, pulse/capillary refill, bleeding
- Management: cleaned, dressed, sutured, imaging requested, referral
- Diagram/photo: use a body chart and photographs only with consent and according to local policy.
The WHO advises describing wounds by site, size, shape, surrounding tissues, colour, course, contents, age/appearance, borders, and depth, using a consistent method. WHO injury-documentation guidance
Examples by body part
1. Head and face
- “A 3 × 1 cm reddish-purple contusion over the left forehead, 2 cm above the left eyebrow, with mild swelling and tenderness. No open wound.”
- “A 2 cm linear laceration over the right parietal scalp with irregular margins and active minimal bleeding.”
- “Abrasions measuring 1 × 0.5 cm over the bridge of the nose.”
Also document: loss of consciousness, vomiting, headache, pupils, vision changes, ear/nose bleeding, and neurological status if relevant.
2. Eye, ear, nose, and mouth
- “Left periorbital ecchymosis measuring 4 × 3 cm, purple-blue in colour, with mild eyelid swelling.”
- “A 1 cm superficial laceration on the inner aspect of the lower lip.”
- “Dried blood present at the right nostril; no active bleeding.”
Avoid stating “black eye” alone. Use the proper site and description.
3. Neck
- “A 5 cm curved, reddish abrasion over the right lateral neck, extending from below the angle of the jaw toward the clavicle.”
- “No neck swelling, tenderness, voice change, difficulty swallowing, or breathing difficulty reported.”
Neck injuries can be serious. Urgent assessment is needed for breathing difficulty, voice change, swallowing difficulty, neck swelling, fainting, or neurological symptoms.
4. Chest, abdomen, and back
- “A 6 × 4 cm bluish-purple bruise over the left lower chest, at the mid-axillary line, tender on palpation.”
- “A 3 cm superficial linear abrasion over the right lower abdomen.”
- “Two parallel linear abrasions, each approximately 7 cm long, over the upper back.”
Document respiratory symptoms, chest tenderness, abdominal guarding, vomiting, and bowel/urinary symptoms where appropriate.
5. Shoulder, arm, elbow, forearm, wrist, and hand
- “A 4 × 2 cm oval bruise on the outer aspect of the right upper arm.”
- “A 2 cm superficial laceration over the dorsum of the left hand between the thumb and index finger.”
- “Swelling and tenderness over the right wrist with painful, reduced range of movement. Distal sensation and capillary refill intact.”
For limb injuries, always note movement, sensation, distal pulses/circulation, and deformity.
6. Hip, thigh, knee, leg, ankle, and foot
- “A 5 × 3 cm abrasion over the anterior right knee with a dry red base and no active bleeding.”
- “Diffuse swelling and tenderness around the left ankle. Unable to bear weight. No open wound seen.”
- “A 2 × 1 cm bruise over the lateral aspect of the left thigh.”
7. Genital or anal injuries
Use precise anatomical language, document only what is examined and observed, and follow consent, chaperone, safeguarding, and forensic procedures. Do not use vague wording such as “injured private parts.” This area should generally be assessed by an appropriately trained clinician.
Short documentation template
Date/time:
History in patient’s own words: “…”
General condition: alert, distressed, stable, etc.
History in patient’s own words: “…”
General condition: alert, distressed, stable, etc.
Injury 1
- Site:
- Type:
- Size:
- Colour/shape/margins:
- Surrounding tissue:
- Tenderness/bleeding:
- Function/neurovascular status:
- Body-chart reference/photo reference:
Treatment/referral:
Clinician name, signature, designation:
Clinician name, signature, designation:
Example complete note
Injury 1: A 4 × 2 cm oval bluish-purple contusion over the lateral aspect of the right upper arm, approximately 8 cm above the elbow. Mild tenderness present. No skin break, swelling, or deformity. Full elbow movement. Distal sensation, radial pulse, and capillary refill normal. Documented on anterior body chart.
Use quotation marks for the patient’s account, for example: Patient states, “I fell on the stairs.” Keep this separate from examination findings. Detailed documentation, including skin examination and injuries found, is important in emergency assessment. ROSEN's Emergency Medicine Concepts and Clinical Practice, block 32, lines 4225-4239.
Give the anatomical name of each part with a diagram
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Use the patient in anatomical position: standing upright, facing forward, arms by the sides, palms facing forward. State right or left from the patient’s perspective.
The standard regional terms are shown in this OpenStax anatomical-terminology diagram.
Anterior view - front of body
| Common name | Anatomical name to write |
|---|---|
| Head | Cranial or cephalic region |
| Forehead | Frontal region |
| Eye | Orbital or ocular region |
| Ear | Otic or auricular region |
| Nose | Nasal region |
| Cheek | Buccal region |
| Mouth | Oral region |
| Chin | Mental region |
| Neck | Cervical region |
| Shoulder tip | Acromial region |
| Collarbone | Clavicular region |
| Chest | Thoracic region |
| Breast | Mammary region |
| Armpit | Axillary region |
| Upper arm | Brachial region |
| Front of elbow | Antecubital region |
| Forearm | Antebrachial region |
| Wrist | Carpal region |
| Palm | Palmar region |
| Fingers | Digital or phalangeal region |
| Thumb | Pollex |
| Abdomen | Abdominal region |
| Navel | Umbilical region |
| Groin | Inguinal region |
| Pubic area | Pubic region |
| Hip | Coxal region |
| Thigh | Femoral region |
| Kneecap/front of knee | Patellar region |
| Lower leg, knee to ankle | Crural region |
| Shin | Anterior tibial region |
| Ankle | Tarsal region |
| Foot | Pedal region |
| Sole | Plantar region |
| Toes | Digital region |
Posterior view - back of body
| Common name | Anatomical name to write |
|---|---|
| Back of head | Occipital region |
| Back of neck | Nuchal region |
| Shoulder blade area | Scapular region |
| Upper back | Posterior thoracic region |
| Spine | Vertebral region |
| Lower back | Lumbar region |
| Area between hips | Sacral region |
| Buttock | Gluteal region |
| Perineum | Perineal region |
| Back of upper arm | Posterior brachial region |
| Point of elbow | Olecranon region |
| Back of forearm | Posterior antebrachial region |
| Back of hand | Dorsum of hand |
| Back of knee | Popliteal region |
| Calf | Sural region |
| Back of lower leg | Posterior crural region |
| Heel | Calcaneal region |
| Sole of foot | Plantar region |
Important terms for describing the exact location
- Anterior / ventral: toward the front
- Posterior / dorsal: toward the back
- Medial: toward the midline
- Lateral: away from the midline
- Superior: nearer the head
- Inferior: nearer the feet
- Proximal: nearer the trunk or point of attachment
- Distal: farther from the trunk or point of attachment
- Palmar: palm surface of hand
- Dorsal: back surface of hand or top surface of foot
- Plantar: sole of foot
Examples for injury writing
- “A 3 × 2 cm reddish abrasion over the anterior right patellar region.”
- “A 4 × 3 cm bluish-purple contusion over the left lateral brachial region.”
- “A 2 cm linear laceration on the dorsum of the right hand, proximal to the second metacarpophalangeal joint.”
- “Tenderness and swelling over the left lateral malleolar region.”
- “A 5 cm linear abrasion over the right posterior scapular region.”
- “A 2 × 1 cm bruise in the left infraorbital region.”
Remember: arm means shoulder to elbow, forearm means elbow to wrist, thigh means hip to knee, and leg means knee to ankle.
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