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.