Laceration without foreign body of vagina and vulva
ICD-10 S31.41 is a billable code used to indicate a diagnosis of laceration without foreign body of vagina and vulva.
S31.41 refers to a laceration of the vagina and vulva that occurs without the presence of a foreign body. This type of injury is often the result of trauma, which can be classified as either blunt or penetrating. Blunt trauma may occur during accidents, falls, or physical assaults, while penetrating trauma can result from sexual assault or surgical procedures. The clinical presentation may include pain, bleeding, and swelling in the affected area. Diagnosis typically involves a thorough physical examination, and imaging studies may be warranted in cases of suspected associated injuries. Treatment often requires surgical intervention to repair the laceration, control bleeding, and prevent infection. The complexity of managing such injuries can be heightened by the potential for concurrent injuries to the pelvic organs, abdominal trauma, or lumbar spine injuries, necessitating a multidisciplinary approach to care.
Detailed account of the injury mechanism, vital signs, and initial treatment provided.
Patients presenting with trauma from accidents, assaults, or childbirth-related injuries.
Ensure comprehensive documentation of any associated injuries and the patient's response to initial treatment.
Thorough documentation of the laceration's location, size, and depth, as well as any surgical repair performed.
Management of lacerations during childbirth or surgical procedures.
Document any complications such as infection or delayed healing.
Used for repair of a laceration of the vagina or vulva.
Document the size and depth of the laceration, as well as the technique used for repair.
Ensure that the procedure is linked to the diagnosis of S31.41.
S31.41 is used for lacerations of the vagina and vulva without foreign bodies, while S31.42 is for cases where a foreign body is present. Accurate documentation is essential to determine the correct code.
