Find comprehensive information on Needle Stick Injuries, including clinical documentation best practices, medical coding guidelines (ICD-10, CPT), exposure management protocols, prevention strategies, and post-exposure prophylaxis (PEP) recommendations for healthcare professionals. Learn about sharps safety, incident reporting, and the importance of accurate medical records related to needle stick incidents and occupational exposures.
Also known as
Needle stick injury
Accidental puncture by a needle during medical care.
Place of occurrence of external cause
Specifies the location where the needlestick injury happened.
Burns and corrosions
If a chemical injection caused a burn from a needlestick.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the needle stick accidental?
Yes
Is infection status known?
No
Is it self-inflicted?
When to use each related code
| Description |
|---|
| Needle stick injury |
| Sharps injury |
| Puncture wound |
Lack of documentation specifying the body part affected by the needle stick injury leads to coding errors and lost revenue.
Missing or unclear documentation about the source of the contaminated needle impacts accurate coding and risk assessment.
Failure to code subsequent treatments, tests (e.g., source individual testing), or prophylactic medications creates audit risks.
Patient presents with a needlestick injury sustained on [date] at approximately [time]. The injury occurred in the [location, e.g., right hand, left index finger] while the patient was [activity resulting in injury, e.g., administering a subcutaneous injection, recapping a needle, disposing of sharps]. The source patient, if applicable, is [source patient name or identifier] and their known bloodborne pathogen status is [status, e.g., positive for Hepatitis C, unknown]. The exposed employee's bloodborne pathogen status is [employee status, e.g., Hepatitis B immune]. The wound was immediately washed with soap and water. The injury site exhibits [description of wound, e.g., pinpoint puncture wound, bleeding, erythema, edema]. Patient reports [symptoms, e.g., pain at the injection site, no other complaints, anxiety regarding potential exposure]. Post-exposure prophylaxis (PEP) was discussed, including risks and benefits. [Document patient's decision regarding PEP, e.g., Patient elected to initiate PEP, Patient declined PEP at this time]. Baseline labs ordered include [list labs, e.g., HIV antibody test, Hepatitis B surface antigen, Hepatitis C antibody test]. Incident reported to occupational health per facility protocol. Patient education provided on signs and symptoms of bloodborne infections, follow-up testing, and prevention of future needlestick injuries. Patient instructed to return for follow-up evaluation on [date]. ICD-10 code: [appropriate ICD-10 code, e.g., X06.0, T23.1XXA].