Laceration Procedural Note

[date name="variable_1" default="today"]
(S): CC: Head laceration
HPI: [text name="variable_2" default="age"] old [text name="variable_3" default="male/female"]was [text name="variable_4" default="history of injury"].
Laceration occurred at [text name="variable_5" default="time"].
Bleeding [select name="variable_6" value="has ceased|is minimal|is profuse|is controlled"]
Associated symptoms: [select name="variable_7" value="none|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"]
Last tetanus toxoid [text name="variable_8" default="years"] ago

Consent: Patient was explained risks and complications of procedure including but not limited to infection, bleeding, scarring. Patient verbalized understanding. All questions answered. Verbal consent received for procedure. No contraindications

(O):
Gen: Looks well. [text name="variable_9" default="level of distress"]
Skin: [text name="variable_10" default="cm"] long laceration to [text name="variable_11" default="location"]. Approximate depth [text name="variable_12" default="cm"].
Wound [text name="variable_13" default="description"]. Debridement [select name="variable_14" value="not required.|required."].
Underlying or nearby tendons: [select name="variable_15" value="none|intact|lacerated|"].
Neurovascular exam: [select name="variable_16" value="intact.|normal capillary refill.|normal sensation to simple touch.|normal 2-point discrimination."]

(A): Suture of laceration

(P):
Closure performed under sterile conditions.
• Skin cleansed well with chlorhexidine and NS solution
• [text name="variable_17" default="number"]cc of 2% Lidocaine [select name="variable_18" value="WITH epinephrine|WITHOUT epinephrine"]injected at the laceration site.
• [text name="variable_19" default="amount"]post-procedure bleeding.
• Skin cleansed well with NS solution
• [text name="variable_20" default="number of sutures"] x [select name="variable_21" value="Steri-strips|Dermabond|3-0 non-absorbable sutures|4-0 non-absorbable sutures|5-0 non-absorbable sutures|6-0 non-absorbable sutures|"]in situ. Wound well approximated.
• Antibiotic ointment and sterile gauze applied and secured with tape
• Pt tolerated well. No complications noted.

Follow-up:
-  Keep dressing dry and intact x 48hrs. After that, may remove dressing and shower. Plain water only, no shampoo or other solutions.
-  Leave incision open to air at night and as possible during the day. Cover with gauze if risk of clothing or other rubbing on suture. May use polysporin if desired
-  Education re: bleeding, signs of infection. RTC if any of these present.
- H/O for wound and suture care provided
-  Suture removal in [select name="variable_23" value="3-5 days: Face, eyelid, eyebrow, nose, lip = 3-5 days|6-8 days: Scalp = 6-8 days|8-10 days: Chest, abdomen = 8-10 days|10-14 days: Hand, ear = 10-14 days|12-14 days: Back, extremities, foot, sole = 12-14 days|"] days
-  Pt agrees with plan. All questions answered. Return to clinic as needed.

(S): CC: Head laceration
HPI: old was .
Laceration occurred at .
Bleeding
Associated symptoms:
Last tetanus toxoid ago

Consent: Patient was explained risks and complications of procedure including but not limited to infection, bleeding, scarring. Patient verbalized understanding. All questions answered. Verbal consent received for procedure. No contraindications

(O):
Gen: Looks well.
Skin: long laceration to . Approximate depth .
Wound . Debridement .
Underlying or nearby tendons: .
Neurovascular exam:

(A): Suture of laceration

(P):
Closure performed under sterile conditions.
• Skin cleansed well with chlorhexidine and NS solution
cc of 2% Lidocaine injected at the laceration site.
post-procedure bleeding.
• Skin cleansed well with NS solution
x in situ. Wound well approximated.
• Antibiotic ointment and sterile gauze applied and secured with tape
• Pt tolerated well. No complications noted.

Follow-up:
- Keep dressing dry and intact x 48hrs. After that, may remove dressing and shower. Plain water only, no shampoo or other solutions.
- Leave incision open to air at night and as possible during the day. Cover with gauze if risk of clothing or other rubbing on suture. May use polysporin if desired
- Education re: bleeding, signs of infection. RTC if any of these present.
- H/O for wound and suture care provided
- Suture removal in days
- Pt agrees with plan. All questions answered. Return to clinic as needed.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.41, 22 form elements, 216 boilerplate words, 13 text boxes, 1 dates, 8 drop downs, 22 total clicks
Questions/General site feedback

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: