I25.2 - Old myocardial infarction

Clinical Definition

A puncture wound with a pointed or sharp instrument or object that creates a small hole but does not show the characteristics of a laceration or more complex wound. The puncture is specifically located on the scalp.

Documentation Requirements

• Location: Must specify exact area of scalp

• Depth: Document if superficial or deep

• Foreign body presence/absence

• Initial vs. subsequent encounter

• Healing status (routine, delayed, etc.)

• Complications if present

• Mechanism of injury (specify instrument/object)

• Associated symptoms

• Size of puncture wound

Common Synonyms

• Scalp hole

• Pin prick to head

• Needle stick in scalp

• Piercing wound to head

• Sharp object wound to scalp

Coding Conflicts

Excludes1:

• Open scalp wounds with significant laceration

• Animal or insect bites

• Penetrating head injuries with intracranial involvement

Excludes2:

• Superficial scalp injuries (scratch/abrasion)

• Multiple puncture wounds

Scribing.io Automation

The AI scribe automatically detects key documentation elements by:

• Identifying terms indicating puncture mechanism ("pierced by," "punctured with")

• Mapping scalp anatomical terms

• Flagging wound characteristics

• Monitoring for complication keywords

• Tracking encounter type (initial/subsequent)

• Capturing healing status descriptors

The system prompts for missing elements required for proper coding, ensuring complete documentation.