Puncture wound with foreign body of finger with damage to nail
ICD-10 S61.34 is a billable code used to indicate a diagnosis of puncture wound with foreign body of finger with damage to nail.
A puncture wound with a foreign body of the finger with damage to the nail is a specific type of injury that occurs when a sharp object penetrates the skin of the finger, potentially embedding a foreign material. This injury can lead to various complications, including infection, damage to underlying structures such as tendons and nerves, and nail bed injury. The presence of a foreign body complicates the healing process and may require surgical intervention for removal. Clinically, patients may present with localized pain, swelling, and redness at the site of injury, along with possible drainage if an infection develops. The nail may exhibit discoloration, detachment, or other signs of trauma. Proper assessment is crucial to determine the extent of the injury, including imaging studies if tendon or nerve damage is suspected. Treatment may involve wound cleaning, foreign body removal, and possibly suturing, along with tetanus prophylaxis if indicated. Follow-up care is essential to monitor for signs of infection and ensure proper healing of the nail and surrounding tissues.
Detailed operative notes describing the injury, foreign body removal, and any repairs performed.
Patients presenting with puncture wounds from nails, glass, or other sharp objects requiring surgical intervention.
Ensure documentation includes the mechanism of injury and any associated injuries to tendons or nerves.
Comprehensive assessment notes including the mechanism of injury, initial treatment provided, and any imaging results.
Patients with acute puncture wounds presenting to the emergency department for evaluation and treatment.
Document all treatments provided, including wound care and foreign body removal, to support coding.
Used when the puncture wound requires suturing.
Operative notes detailing the repair process and any foreign body removal.
Orthopedic surgeons should document the extent of the injury and any repairs performed.
Documenting the foreign body is crucial as it impacts the treatment plan, potential complications, and the accuracy of coding. It ensures that the medical record reflects the complexity of the injury and supports the use of specific codes.
