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Laceration Repair & I&D Procedure Note
Oct 5, 2019
•
Mark Morgan
categories:
Procedure Note
Injury & Poisoning
LACERATION REPAIR PROCEDURE NOTE
INCISION AND DRAINAGE PROCEDURE NOTE
PHYSICAL EXAM:
-Wound location -
Scalp
Face
Neck
Shoulder
Chest/Trunk
Abdomen
Buttocks
Inguinal
Male Genital Region
Female Genital Region
Arm
Elbow
Forearm
Wrist
Hand
Finger
Hip
Thigh
Knee
Leg
Ankle
Foot
Toe
-
right
left
midline
occipital
parietal
temporal
frontal
preauricular
postauricular
area
-
right
left
midline
preauricular
mandibular angle
cheek
nose
periorbital
perioral
chin
submandibular
submental
area
-
right
left
midline
,
anterior
posterior
medial
lateral
,
superior
inferior
middle
aspect
-
right
left
,
anterior
posterior
medial
lateral
aspect
-
right
left
,
anterior
posterior
medial
lateral
,
superior
inferior
middle
aspect
-
right
left
midline
,
anterior
posterior
medial
lateral
,
superior
inferior
middle
aspect
-
periumbilical
epigastrium
RUQ
LUQ
RLQ
LLQ
aspect
-
right
left
midline
medial
lateral
perianal
gluteal cleft
cheek
gluteal fold
-
right
left
-
right
left
midline
penile glans
penile shaft
base of penis
scrotum
periscrotal area
-
right
left
midline
labia majora
labia minora
perilabial area
periclitoral area
mons pubis
perineum
-
right
left
,
palmar/volar
dorsal
medial
lateral
aspect
,
1st
2nd
3rd
4th
5th
digit,
MCP
proximal phalanx
middle phalanx
distal phalanx
periungual area
-
right
left
,
plantar
dorsal
medial
lateral
aspect
,
1st
2nd
3rd
4th
5th
digit,
MTP
proximal phalanx
middle phalanx
distal phalanx
periungual area
-Wound size/diameter -
cm
mm
-Tissue layers damaged/affected -
epidermis
dermis
subcutaneous layer
muscle/tendon
periosteum/bone
-Hemostatic -
Yes
NO
-Wound approximation -
good
marginal
POOR
-Debris/foreign body present -
PROCEDURE: LACERATION REPAIR -
complexity
simple
intermediate
complex
-
location
scalp/neck/axillae/external genitalia/trunk/extremities
face/ear/eyelid/nose/lips/mucous membrane
-
size
2.5cm or less
2.6-7.5cm
7.6-12.5cm
12.6-20.0cm
20.1-30.0cm
30.1cm or greater
-CPT Code:
calc'd value
score=(laccomplexity)+(laclocationsimple)+(lacsizesimple)
-
location
scalp/axillae/trunk/extremities NOT hands/feet
neck/hands/feet/external genitalia
face/ears/eyelids/nose/lips/mucous membranes
-
size
2.5cm or less
2.6-7.5cm
7.6-12.5cm
12.6-20.0cm
20.1-30.0cm
30.1cm or greater
-CPT Code:
calc'd value
score=(laccomplexity)+(laclocationintermediate)+(lacsizeintermediate)
-
location
trunk
scalp/arms/legs
face/ears/eyelids/nose/lips/mucous membranes
forehead/cheeks/chin/mouth/neck/axillae/genitalia/hands/feet
eyelids/nose/ears/lips
-
size
2.5cm or less
2.6-7.5cm
7.6-12.5cm
12.6-20.0cm
20.1-30.0cm
30.1cm or greater
-CPT Code:
calc'd value
score=(laccomplexity)+(laclocationcomplex)+(lacsizecomplex)
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
SUPERVISING PHYSICIAN - Dr.
type of consent (choose one)
verbal
written
INDICATIONS/COUNSELING:
-Discussed reason and medical indication(s) for procedure which include(s):
improve hemostasis of wound
improve healing time of wound
prevent excess scarring to ensure optimal return of full function of affected area
-Discussed and patient demonstrated understanding of:
-limitations and risks of procedure
-risk/likelihood of pain during/after procedure
-risk/likelihood of bleeding during/after procedure
-risk/likelihood of infection after procedure
-risk/likelihood of scarring after procedure
-complications from anesthesia/analgesia during/after procedure
-possibility of repeat procedure needed
-Discussed alternatives to procedure which include: leaving wound to heal by secondary intent.
-Patient acknowledged understanding of the above items and desired to proceed.
-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:
-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:
-Wound cleansing was performed in usual fashion with
irrigation with tap water
irrigation with sterile saline
gentle scrub with soapy water
forceps removal of visible debris/foreign body
debridement
-Tissue debridement performed.
speech input
description
-Once wound determined sufficiently clean for closure, it was prepared and draped in usual fashion using
Betadine/Iodine
Chlorhexidine
per manufacturer and infection control recommendations.
-Anesthetic approach was
local/field block
digital block
regional block
.
The skin overlying the indentified lesion infiltrated with above anesthetic agent.
Above anesthetic was used to perform block in usual fashion of
R
L
1st
2nd
3rd
4th
5th
finger
toe
.
speech input
description
-Deeper wound closure was required to best reapproximate and prepare the wound for final closure. This was performed subcutaneously
in running fashion
with single horizontal suture
using
3-0
4-0
Vicryl
Monocryl
PDS
suture material.
-
Final
Wound
closure was performed with
simple interrupted sutures using
3-0
4-0
5-0
6-0
Ethilon/nylon
Prolene/polypropylene
silk
suture material.
freetext comments about suturing
-EBL was less than 1ml and good hemostasis noted.
-Antibiotic ointment and a bandage were applied.
PHYSICAL EXAM:
-Lesion location -
Scalp
Face
Neck
Shoulder
Chest/Trunk
Abdomen
Buttocks
Inguinal
Male Genital Region
Female Genital Region
Arm
Elbow
Forearm
Wrist
Hand
Finger
Hip
Thigh
Knee
Leg
Ankle
Foot
Toe
-
right
left
midline
occipital
parietal
temporal
frontal
preauricular
postauricular
area
-
right
left
midline
preauricular
mandibular angle
cheek
nose
periorbital
perioral
chin
submandibular
submental
area
-
right
left
midline
,
anterior
posterior
medial
lateral
,
superior
inferior
middle
aspect
-
right
left
,
anterior
posterior
medial
lateral
aspect
-
right
left
,
anterior
posterior
medial
lateral
,
superior
inferior
middle
aspect
-
right
left
midline
,
anterior
posterior
medial
lateral
,
superior
inferior
middle
aspect
-
periumbilical
epigastrium
RUQ
LUQ
RLQ
LLQ
aspect
-
right
left
midline
medial
lateral
perianal
gluteal cleft
cheek
gluteal fold
-
right
left
-
right
left
midline
penile glans
penile shaft
base of penis
scrotum
periscrotal area
-
right
left
midline
labia majora
labia minora
perilabial area
periclitoral area
mons pubis
perineum
-
right
left
,
palmar/volar
dorsal
medial
lateral
aspect
,
1st
2nd
3rd
4th
5th
digit,
MCP
proximal phalanx
middle phalanx
distal phalanx
periungual area
-
right
left
,
plantar
dorsal
medial
lateral
aspect
,
1st
2nd
3rd
4th
5th
digit,
MTP
proximal phalanx
middle phalanx
distal phalanx
periungual area
-Lesion size/diameter -
cm
mm
-Characteristics -
erythema
edema
induration
fluctuance
tenderness to palpation
drainage
-
purulent
serous
sanguinous/bloody
PROCEDURE: ABSCESS INCISION AND DRAINAGE -
simple/single
complicated/multiple
CPT Code:
10060
10061
Select COMPLICATED for any of the following-
-Multiple incisions
-Drain placements
-Probing to break up loculations
-Extensive packing
-Subsequent wound closure
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
SUPERVISING PHYSICIAN - Dr.
type of consent (choose one)
verbal
written
INDICATIONS/COUNSELING:
-Discussed reason and medical indication(s) for procedure which include(s):
prevention of infection spread
reduced likelihood of requiring antibiotics
quicker resolution of abscess
-Discussed and patient demonstrated understanding of:
-limitations and risks of procedure
-risk/likelihood of pain during/after procedure
-risk/likelihood of bleeding during/after procedure
-risk/likelihood of infection after procedure
-risk/likelihood of scarring after procedure
-complications from anesthesia/analgesia during/after procedure
-possibility of repeat procedure needed
-Discussed alternatives to procedure which include: antibiotics and followup.
-Patient acknowledged understanding of the above items and desired to proceed.
-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:
-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:
-The skin overlying/surrounding the indentified lesion was infiltrated with above anesthetic agent.
-Using
#11
#15
#10
blade scalpel, performed
cm
mm
linear incision over lesion.
-Expressed/drained
mucopurulent
sanguinous/bloody
material.
-Probed wound for loculations and
no loculations found.
loculations were broken up with additional drainage.
-Total amount of material drained:
ml
-Wound irrigated with
ml of
.
-Wound packed with
plain
iodoform
ribbon gauze.
-Wound was overdressed in usual fashion.
PATIENT DISPOSITION
-Patient tolerated overall procedure well.
-No immediate complications noted.
-Discussed with patient return precautions to include: fever, erythema, swelling, pain, or purulent discharge from the wound.
-Post-procedure care of surgical wound discussed.
-Patient instructed to return for suture removal in
days.
-Discussed with patient return precautions to include: fever, progressive pain/swelling.
-Post-procedure care of surgical wound discussed.
-F/U in
day(s) for wound repacking
-Patient left in stable condition.
speech input
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