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Laceration Note
Nov 20, 2010
•
Mark Morgan
categories:
Procedure Note
Dermatology & Wounds
Injury & Poisoning
Subjective:
History provided by
patient
mother
father
spouse
son
daughter
grandparent
daycare provider
friend
other -
Brief history narrative here
speech input
When did the laceration occur?
Laceration occurred less than six hours ago.
Laceration occurred less than 12 hours ago.
Laceration occurred more than 12 hours ago.
Laceration occurred one day ago.
Laceration occurred more than one day ago.
Bleeding?
Bleeding has ceased.
Bleeding is minimal.
Bleeding was minimal.
Bleeding continues.
Bleeding is controlled.
Bleeding is profuse.
Accompanying symptoms:
no other symptoms
no loss of sensation related to the injury
full range of motion of involved body part
no symptoms of vascular compromise
loss of sensation distal to the injury
Tetanus toxoid:
up to date
less than five years ago
between 5 - 10 years ago
greater than 10 years ago
unknown
Objective:
Patient level of distress
no distress.
mild distress.
moderate distress.
severe distress.
Location:
chin
cheek
forehead
scalp
finger
hand
arm
toe
foot
leg
chest
back
other -
Laceration modifiers
Left
Right
Proximal
Distal
First
Second
Third
Fourth
Fifth
Length:
Depth:
Wound description:
clean.
dirty.
linear.
jagged.
flap-like.
swollen.
bleeding.
bleeding profusely.
cyanotic tissue present.
devitalized tissue present.
other -
Debridement not required.
Debridement required.
No underlying or nearby tendons.
Underlying/nearby tendons intact.
Underlying/nearby tendons are lacerated.
Neurovascular exam:
intact.
normal capillary refill.
normal sensation to simple touch.
normal 2-point discrimination.
other -
Assessment and Plan:
Closure not performed
Closure performed
Risks, benefits, alternatives discussed. Consent obtained. Prepped and draped in usual sterile fashion.
speech input
Anesthesia:
Skin closure materials:
Dermabond
Steri-Strips
3-O nonabsorbable suture
4-O nonabsorbable suture
5-0 nonabsorbable suture
6-0 nonabsorbable suture
7-0 nonabsorbable suture
3-O for feet, 4-O for scalp, chest, abdomen, foot, or extremity, 5-0 for scalp, brow, oral, chest, abdomen, hand, 6-0 for ear, lid, brow, nose, lip, face, 7-0 for eyelid, lip, face
Other details:
good hemostasis.
good cosmetic results.
patient tolerated procedure well.
topical antibiotic applied. white petroleum dressing applied.
sterile dressing applied.
no complications
Follow up:
Local wound care discussed.
Observe for signs of infection, bleeding, and follow up promptly if these symptoms occur.
Suture removal in
3-5 days: Face, Eyelid, Eyebrow, Nose, Lip
6-8 days: Scalp
8-10 days: Chest and abdomen
10-14 days: Hand, Ear
12-14 days: Back, Extremities, Foot, and Sole
display/hide references
reference:
#1
Family Practice Notebook Wound Repair Page
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