Laceration Note

Complete Note, Procedure Note
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[html]Summary: Complete SOAP note for laceration repair.
[/html]Subjective:
History provided by [select name="Q1" value="patient|mother|father|spouse|son|daughter|grandparent|daycare provider|friend|other - "][conditional field="Q1" condition="(Q1).is('other - ')"][text][/conditional]
[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. "]
[select value="Bleeding?|Bleeding has ceased. |Bleeding is minimal. |Bleeding was minimal. |Bleeding continues. |Bleeding is controlled. |Bleeding is profuse. "]
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"]

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 - "][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. "]
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.
Observe for signs of infection, bleeding, and follow up promptly if these symptoms occur.
[conditional field="Q5" condition="(Q5).is('Closure performed')"]Suture removal in [select value="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"][/conditional]
[html]<hr>[/html][checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"][html]
reference: <a href="http://www.fpnotebook.com/Surgery/DER/WndRpr.htm" target="_blank">Family Practice Notebook Wound Repair Page</a>[/html][/conditional]
Summary: Complete SOAP note for laceration repair.
Subjective:
History provided by



Accompanying symptoms:

Tetanus toxoid:

Objective:

Location:
Laceration modifiers
Length:
Depth:
Wound description:


Neurovascular exam:

Assessment and Plan:

Follow up:
Local wound care discussed.
Observe for signs of infection, bleeding, and follow up promptly if these symptoms occur.


display/hide references
Result - Copy and paste this output:

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