A scar after a healed traumatic wound

Read an original fictional chart, identify the supported facts, and explain your coding workflow.

Chart gym · Original fictional record

Service date: 2026-09-01 · Outpatient professional service

Use your code books and write your reasoning before opening the walkthrough. This exercise contains no real patient information.

Reason for care

The patient attends an outpatient visit for treatment of a symptomatic scar on the left forearm. The clinician explicitly attributes the scar to an earlier traumatic laceration.

Prior injury

The original wound is fully healed. The clinician is not providing routine healing care for an open laceration and identifies no new injury.

Assessment and plan

The scar is the residual condition addressed today. The record establishes its relationship to the old injury.

Task boundary

Explain the injury-sequela sequence. The task does not ask the learner to report a newly occurring laceration or to select an unprovided treatment procedure.

Your coding worksheet

Name the condition receiving care today.
Identify why the old injury is still relevant.
State the usual residual-condition and injury-sequela sequence.
Explain which entry receives the sequela character.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.

Compare with the worked explanation

The scar, rather than an actively healing wound, receives care today.
The old laceration is the documented cause of the residual condition.
The residual condition is sequenced first, followed by the responsible injury entry with the sequela character.
The injury entry receives the sequela character. Verify its full structure; do not append that character to the scar entry.

Reference sections: I.C.19.a

Practice the linked chart questions