Open wound of vagina and vulva
ICD-10 S31.4 is a billable code used to indicate a diagnosis of open wound of vagina and vulva.
An open wound of the vagina and vulva refers to a traumatic injury that results in a break in the skin or mucous membrane of the female genitalia. This type of injury can occur due to various mechanisms, including blunt or penetrating trauma, surgical procedures, or childbirth. The clinical presentation may include lacerations, abrasions, or puncture wounds, which can lead to significant bleeding, pain, and risk of infection. In cases of severe trauma, associated injuries may involve the pelvic organs, such as the bladder or rectum, necessitating a thorough evaluation for concurrent genitourinary injuries. Emergency surgical intervention may be required to control bleeding, repair the wound, and prevent complications. The management of these injuries often involves a multidisciplinary approach, including trauma surgeons, gynecologists, and urologists, particularly in cases of complex pelvic injuries or when there is a risk of significant organ damage.
Detailed documentation of the mechanism of injury, extent of the wound, and any associated injuries.
Trauma from vehicular accidents, falls, or assaults leading to vaginal and vulvar injuries.
Ensure accurate coding of any surgical procedures performed to repair the wound.
Comprehensive notes on the patient's history, examination findings, and treatment plan.
Injuries sustained during childbirth or gynecological surgeries.
Document any complications such as infections or need for further surgical intervention.
Used in cases where surgical intervention is required for extensive vulvar injuries.
Detailed operative notes describing the extent of the injury and the procedure performed.
Trauma surgeons and gynecologists should collaborate on documentation.
Coders need detailed documentation of the mechanism of injury, the extent of the wound, any associated injuries, and the surgical interventions performed.
