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Toenail Removal Procedure Note
Mar 20, 2019
•
Mark Morgan
categories:
Procedure Note
TOENAIL REMOVAL
PRE-OP DIAGNOSIS:
Ingrowing Nail - L60.0
Tinea unguium - B35.1
POST-OP DIAGNOSIS:
Ingrowing Nail - L60.0
Tinea unguium - B35.1
PROCEDURE:
Complete Toenail Removal without matrix ablation - 11730
Partial Toenail Removal without matrix ablation - 11730
Complete Toenail Removal WITH matrix ablation - 11750
of
Right
Left
1st/Great
2nd
3rd
4th
5th
Toenail
ANESTHESIA AGENT(S):
Lidocaine 1% with epinephrine
Lidocaine 1% without epinephrine
Lidocaine 2% with epinephrine
Lidocaine 2% without epinephrine
Marcaine 0.5%
Bicarbonate buffering solution
-Total amt used:
ml
Supervising Physician:
Dr.
type of consent
verbal
written
INDICATIONS/COUNSELING:
-Patient desires toe nail removal and is medically indicated
-Discussed risks of procedure which include:
bleeding
pain
infection
scarring
recurrence of condition
failure to remove affected nail
need for repeat procedure
.
-Discussed alternatives to procedure which include:
proper trimming of nails
inserting cotton under nail edges
other-
-Patient consent and timeout were performed verbally in lieu of written consent due to:
austere medical conditions
high patient volume and unavailability of support staff to assist
unavailability of accessible/printed forms
-Patient made aware of above conditions preventing written consent and agreed to proceed.
-A time out was performed prior to the procedure ensuring:
-Confirmed that consent form appropriately signed and hardcopy to be scanned into patient's medical record.
-A time out was performed prior to the procedure and documented in a hardcopy form to be scanned into patient's record to include ensuring:
only select what's applicable
--Patient was identified using full name and DOB.
--Patient was evaluated and medical record reviewed including history and lab/imaging findings if applicable.
--Procedure and site/side matches the consent form.
--Patient was involved in the site/side marking.
--For final timeout, physician paused or verbally confirmed with procedure team of:
---correct patient, correct procedure, and correct site/side.
---The patient has been positioned correctly for the procedure.
---All necessary equipment are available.
--Instrument sterility verified.
PROCEDURE
-Toe was cleansed with
Betadine/Iodine
Chlorhexidine
per manufacturer and infection control recommendations.
-Performed digital block of the
ToeLoc1
ToeLoc2
toe using anesthetic agent(s) listed above.
-Toe tourniquet was placed for hemostasis.
-Elevated
affected portion of
complete
nail plate from matrix and freed from adjacent cuticle and periungual skin.
-Cut elevated/freed portion of nail plate and removed.
-Removed complete nail plate.
-Electrocautery was used to ablate the nail-forming matrix beneath the area where the nail plate was removed.
-Phenol was used
to ablate the nail-forming matrix beneath the area where the nail plate was removed. Phenol applied with cotton swab to matrix for 30 seconds, and repeated 3 times. Matrix then was thoroughly cleansed with isopropyl Alcohol 70%.
-EBL
less than 1ml
.
-Toe was then gently irrigated with saline irrigation
-Bacitracin and Telfa gauze was applied.
-Regular gauze was placed and bandage secured with
Coban dressing
Sock dressing
.
-Instructed the patient to follow up for fever, erythema, swelling, pain, or foul-smelling purulent discharge from the wound.
PATIENT DISPOSITION
-Patient tolerated overall procedure(s) well
-No immediate complications noted
-Patient left in stable condition with appropriate counseling as described above.
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