laceration

Subjective:
[textarea default="Brief history narrative here"]
[select value="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.  "]
Objective:
[select value="Patient level of distress|no distress.  |mild distress.  |moderate distress.  |severe distress.  "]
Location:  [select name="Q2" value="chin|cheek|forehead|scalp|finger|hand|arm|toe|foot|leg|chest|back|other - "][conditional field="Q2" condition="(Q2).is('other - ')"][text][/conditional]
[comment memo="Laceration modifiers"][checkbox value="Left|Right|Proximal|Distal|First|Second|Third|Fourth|Fifth"]
Length:  [text]
Depth:  [text]
Wound description:  [select name="Q3" value="clean.  |dirty.  |linear.  |jagged.  |flap-like.  |swollen.  |bleeding.  |bleeding profusely.  |cyanotic tissue present.  |devitalized tissue present.  |other - "]
[select value="Bleeding?|Bleeding has ceased.  |Bleeding is minimal.  |Bleeding was minimal.  |Bleeding continues.  |Bleeding is controlled.  |Bleeding is profuse.  "][conditional field="Q3" condition="(Q3).is('other - ')"][text][/conditional]
[select value="Debridement not required.  |Debridement required.  "]
[select value="No underlying or nearby tendons.  |Underlying/nearby tendons intact.  |Underlying/nearby tendons are lacerated.  "]
Accompanying symptoms:  
[checkbox value="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:  [select value="up to date|less than five years ago|between 5 - 10 years ago|greater than 10 years ago|unknown"]
Neurovascular exam:  [checkbox name="Q4" value="intact.  |normal capillary refill.  |normal sensation to simple touch.  |normal 2-point discrimination.  |other - "][conditional field="Q4" condition="(Q4).is('other - ')"][text][/conditional]
Assessment and Plan:
[select name="Q5" value="Closure not performed|Closure performed"][conditional field="Q5" condition="(Q5).is('Closure performed')"]
[textarea default="Risks, benefits, alternatives discussed.  Consent obtained.  Prepped and draped in usual sterile fashion.  "]
Anesthesia:  [text]
Skin closure materials:  [text]
[select value="Dermabond|Steri-Strips|3-O nonabsorbable suture|4-O nonabsorbable suture|5-0 nonabsorbable suture|6-0 nonabsorbable suture|7-0 nonabsorbable suture" memo="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"]
[text default="number of sutures"]
Other details: [checkbox value="good hemostasis.  |good cosmetic results.  |patient tolerated procedure well.  |topical antibiotic applied.  white petroleum dressing applied.  |sterile dressing applied.  |no complications"][/conditional]
Follow up:
Local wound care discussed, keep wound covered and clean while working.
Observe for signs of infection (redness, swelling, drainage), bleeding, and follow up promptly if these symptoms occur.