Medical Documentation of a Raised Hematoma on the Left Leg
Document this as: "2 x 2 cm raised hematoma, left leg" or "2 x 2 cm subcutaneous hematoma with elevation, left leg."
Standard Charting Components
When documenting a hematoma in medical records, include these specific descriptors to ensure complete clinical documentation:
Size and Location
- Dimensions: Record the hematoma as "2 x 2 cm" (length x width), which is standard medical terminology for describing lesion size 1
- Anatomic location: Specify the exact location on the left leg (e.g., "anterior thigh," "lateral calf," "medial shin") rather than just "left leg" for precise anatomic documentation 1
Physical Characteristics
- Elevation: The term "raised" should be documented as either "elevated," "with elevation," or "subcutaneous" to indicate the hematoma extends above the skin surface 1
- Consistency: Note whether the lesion is firm, fluctuant, or compressible on palpation 1
- Overlying skin: Document any color changes (ecchymosis, erythema), warmth, or skin integrity changes 1
Additional Clinical Details to Include
- Tenderness: Note presence or absence of tenderness to palpation 1
- Peripheral pulses: Document distal pulses (dorsalis pedis, posterior tibial) to assess vascular compromise 1
- Neurovascular status: Record any sensory or motor deficits, as hematomas can cause nerve compression, particularly femoral nerve involvement with thigh hematomas 2
- Compartment assessment: Note any signs of compartment syndrome (tense swelling, pain out of proportion, paresthesias) 1
Complete Documentation Example
A comprehensive chart entry would read:
"2 x 2 cm raised subcutaneous hematoma, lateral left thigh, firm to palpation, non-tender, overlying skin with mild ecchymosis, no warmth or erythema. Distal pulses intact. No sensory or motor deficits. No signs of compartment syndrome."
Important Clinical Considerations
- Anticoagulation status: Always document if the patient is on anticoagulant or antiplatelet therapy, as this significantly impacts management and risk assessment 3, 4, 2
- Mechanism of injury: Note whether traumatic or spontaneous, as spontaneous hematomas warrant investigation for underlying coagulopathy 5, 2
- Progressive symptoms: Document any progression in size, pain, or development of neurological symptoms, which may indicate need for imaging or surgical intervention 6, 2