Comprehensive HPI Template for Laceration Assessment
A thorough laceration HPI template should include mechanism of injury, timing, wound characteristics, and associated symptoms to guide appropriate treatment decisions and optimize outcomes. 1
Essential HPI Elements
Injury Details
- Mechanism of injury: How the laceration occurred (sharp object, blunt trauma, crush injury, bite)
- Time of injury: Exact time since injury occurred (critical for closure decisions)
- Location of injury: Precise anatomical location
- Circumstances: Activity during injury (work-related, sports, household accident)
Wound Characteristics
- Size: Length, width, and depth measurements
- Appearance: Edges (clean-cut vs. jagged), tissue loss, visible foreign bodies
- Depth: Involvement of structures (skin only, subcutaneous tissue, muscle, tendon, nerve, vessel)
- Contamination: Presence of dirt, debris, or foreign material
- Bleeding: Active, controlled, or hemostatic
Associated Symptoms
- Pain: Severity, character, and radiation
- Functional impairment: Range of motion limitations, sensory changes
- Neurovascular status: Distal sensation, capillary refill, pulses
Patient Factors
- Tetanus immunization status: Last booster date
- Allergies: Particularly to anesthetics or antibiotics
- Comorbidities: Diabetes, peripheral vascular disease, immunocompromise
- Medications: Anticoagulants, immunosuppressants
Special Considerations
High-Risk Features
- Location: Near joints, cosmetically sensitive areas (face), high-tension areas
- Contamination risk: Animal/human bites, soil, fecal matter
- Vascular compromise: Injuries affecting blood supply
- Functional structures: Tendons, nerves, specialized tissue (lips, eyelids)
Red Flags
- Signs of infection: Erythema, warmth, purulent discharge
- Neurovascular compromise: Numbness, tingling, poor capillary refill
- Foreign body sensation: Patient reports feeling something in the wound
- Extensive tissue damage: Avulsion, devitalized tissue
Documentation Example
"26-year-old male presents with a laceration to the right index finger sustained 2 hours ago while cutting vegetables with a kitchen knife. The wound is approximately 3 cm long, extends through the dermis with visible subcutaneous fat, has clean edges, and minimal active bleeding. Patient reports moderate pain (6/10) without numbness or tingling. Full range of motion is preserved. Tetanus up to date (booster 3 years ago). No allergies to medications. No significant medical history."
By systematically documenting these elements, clinicians can properly assess lacerations, determine appropriate closure techniques, and identify patients requiring specialized care or follow-up 1, 2.