Procedure Note
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CONSENT:
[checkbox name="consent" value="procedure, risks, benefits, alternatives explained|patient/SO voiced understanding & agreed to proceed|consent signed|verbal consent obtained"]

REPORTS:
[checkbox name="report" value="no fever/chills|no loss of sensation distal to injury"]

TETANUS:
[checkbox name="tetanus" value="up to date|less than five years ago|5-10 years ago|greater than 10 years ago|unknown"]

LOCATION: [select name="Q2" value="face|posterior neck|arm|hand|thigh|leg|foot|chest|back|flank|axillary|inguinal|buttocks|perirectal|"][conditional field="Q2" condition="(Q2).is('other - ')"][text][/conditional][checkbox value="left|right||first|second|third|fourth|fifth||proximal|distal||medial|lateral|dorsal|ventral"][textarea cols=40 rows=1]
SIZE:
[checkbox name="size" value="<2.6 cm|2.6–5.0 cm|5.1–7.5 cm|7.6-12.5 cm|12.6-20.0 cm|20.1-30.0 cm|>30.0 cm|"][textarea cols=40 rows=1]
ABSCESS:
[checkbox name="abscess" value="pointing|fluctuant|drainings|"][textarea cols=40 rows=1]
SURROUNDING SKIN:
[checkbox name="skin" value="induration|swelling|tenderness|erythema|"][textarea cols=40 rows=1]
REGIONAL:
[checklist name="regional" value="lymphangitis|LAD"][textarea cols=40 rows=1]

PREP:
[checkbox name="prep" value="skin cleaned with wound cleanser|skin cleaned with hibiclens|skin cleaned with Betadine||draped in normal sterile fashion|"][textarea cols=40 rows=1]
ANESTHESIA:
[checkbox name="anesthesia" value="[checkbox name="anesthesia" value="field block/local infiltration||lido 1%|lido 2%|with epi|with bicarb|"][textarea cols=40 rows=1]

PROCEDURE:
[checkbox name="procedure" value="#11 blade used|#15 blade used|linear incision made along local skin lines||expressed small amount|expressed moderate amount|expressed large amount||purulent material|bloody material|serous material||culture obtained||cavity probed to break up loculations||irrigated with plenty of NS||1/4 packing strip inserted|1/2 packing strip inserted||bleeding insignificant stopped with pressure||covered with non-adherent dressing|applied bulky gauze dressing||NVT reassessment intact|patient tolerated procedure well|"][textarea cols=40 rows=1]

INSTRUCTED:
[checkbox name="instructed" value="wound check in 2 days|return immediately for increasing pain, swelling, redness, drainage, fever||keep wound dry||remove packing in 24 hours||clean skin with soap and water daily|change dressing daily|"][textarea cols=40 rows=1]
CONSENT:


REPORTS:


TETANUS:


LOCATION:
SIZE:

ABSCESS:

SURROUNDING SKIN:

REGIONAL:


PREP:

ANESTHESIA:


PROCEDURE:


INSTRUCTED:
Result - Copy and paste this output: