Unspecified open wound of left middle finger without damage to nail
ICD-10 S61.203 is a billable code used to indicate a diagnosis of unspecified open wound of left middle finger without damage to nail.
An unspecified open wound of the left middle finger refers to a traumatic injury that results in a break in the skin, exposing underlying tissues without affecting the nail. Such wounds can occur due to various incidents, including cuts, lacerations, or punctures. The left middle finger is particularly susceptible to injuries due to its frequent use in grasping and manipulating objects. Clinically, these wounds may present with bleeding, swelling, and pain, and they require careful assessment to rule out associated injuries such as fractures, tendon damage, or nerve involvement. Treatment typically involves cleaning the wound, possibly suturing, and monitoring for signs of infection. The absence of nail damage simplifies the clinical picture, but thorough documentation is essential to capture any potential complications or associated injuries that may arise from the trauma.
Detailed notes on the mechanism of injury, assessment of associated injuries, and treatment plan.
Fractures associated with open wounds, tendon repairs, and surgical interventions.
Ensure to document any surgical procedures performed, including the type of repair and materials used.
Comprehensive assessment of the wound, including size, depth, and any foreign bodies.
Acute presentations of hand injuries, management of lacerations, and initial wound care.
Document the initial treatment provided and any referrals made for follow-up care.
Used when the wound requires suturing or closure.
Document the size of the wound and the method of closure.
Orthopedic surgeons may perform more complex repairs if associated injuries are present.
Document the mechanism of injury, size and depth of the wound, any associated injuries, treatment provided, and follow-up care instructions.
