Laceration Repair & I&D Procedure Note

[checkbox name="proctypeLaceration" value="LACERATION REPAIR PROCEDURE NOTE"][conditional field="proctypeLaceration" condition="(proctypeLaceration).isNot('LACERATION REPAIR PROCEDURE NOTE')"][comment memo="
" memo_color="whitesmoke" memo_size="small"][/conditional][checkbox name="proctypeIncisionDrainage" value="INCISION AND DRAINAGE PROCEDURE NOTE"][conditional field="proctypeLaceration" condition="(proctypeLaceration).is('LACERATION REPAIR PROCEDURE NOTE')"]

[checkbox name="woundPE" value="PHYSICAL EXAM:"][/conditional][conditional field="woundPE" condition="(woundPE).is('PHYSICAL EXAM:')"]
-Wound location - [select name="woundexamlocation1" value="|Scalp|Face|Neck|Shoulder|Chest/Trunk|Abdomen|Buttocks|Inguinal|Male Genital Region|Female Genital Region|Arm|Elbow|Forearm|Wrist|Hand|Finger|Hip|Thigh|Knee|Leg|Ankle|Foot|Toe"][/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Scalp')"]- [select value="right|left|midline"] [select value="occipital|parietal|temporal|frontal|preauricular|postauricular"] area[/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Face')"]- [select value="right|left|midline"] [select value="preauricular|mandibular angle|cheek|nose|periorbital|perioral|chin|submandibular|submental"] area[/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Neck')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Shoulder')||(woundexamlocation1).is('Elbow')||(woundexamlocation1).is('Wrist')||(woundexamlocation1).is('Hip')||(woundexamlocation1).is('Knee')||(woundexamlocation1).is('Ankle')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"] aspect[/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Arm')||(woundexamlocation1).is('Forearm')||(woundexamlocation1).is('Thigh')||(woundexamlocation1).is('Leg')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Chest/Trunk')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Abdomen')"]- [select value="periumbilical|epigastrium|RUQ|LUQ|RLQ|LLQ"] aspect[/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Buttocks')"]- [select value="right|left|midline"] [select value="|medial|lateral"] [select value="perianal|gluteal cleft|cheek|gluteal fold"][/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Inguinal')"]- [select value="right|left"][/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Male Genital Region')"]- [select value="right|left|midline"] [select value="penile glans|penile shaft|base of penis|scrotum|periscrotal area"][/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Female Genital Region')"]- [select value="right|left|midline"] [select value="labia majora|labia minora|perilabial area|periclitoral area|mons pubis|perineum"][/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Hand')||(woundexamlocation1).is('Finger')"]- [select value="right|left"], [checkbox value="palmar/volar|dorsal|medial|lateral"] aspect[/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Finger')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MCP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Foot')||(woundexamlocation1).is('Toe')"]- [select value="right|left"], [checkbox value="plantar|dorsal|medial|lateral"] aspect[/conditional][conditional field="woundexamlocation1" condition="(woundexamlocation1).is('Toe')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MTP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="woundPE" condition="(woundPE).is('PHYSICAL EXAM:')"]
-Wound size/diameter - [text size="8"] [select value="cm|mm"]
-Tissue layers damaged/affected - [checkbox value="epidermis|dermis|subcutaneous layer|muscle/tendon|periosteum/bone"]
-Hemostatic - [select value="|Yes|NO"]
-Wound approximation - [select value="|good|marginal|POOR"]
-Debris/foreign body present - [text default="no" size="20"]

[/conditional][conditional field="proctypeLaceration" condition="(proctypeLaceration).is('LACERATION REPAIR PROCEDURE NOTE')"]

PROCEDURE: LACERATION REPAIR - [comment memo="complexity" memo_size="small"][select name="laccomplexity" value="|simple=12000|intermediate=12030|complex=13100"][/conditional][conditional field="laccomplexity" condition="(laccomplexity).is('simple=12000')"] - [comment memo="location" memo_size="small"][select name="laclocationsimple" value="scalp/neck/axillae/external genitalia/trunk/extremities=0|face/ear/eyelid/nose/lips/mucous membrane=10"] - [comment memo="size" memo_size="small"][select name="lacsizesimple" value="2.5cm or less=1|2.6-7.5cm=2|7.6-12.5cm=4|12.6-20.0cm=5|20.1-30.0cm=6|30.1cm or greater=7"]
-CPT Code: [calc value="score=(laccomplexity)+(laclocationsimple)+(lacsizesimple)" memo="calc'd value" memo_size="small"][/conditional][conditional field="laccomplexity" condition="(laccomplexity).is('intermediate=12030')"] - [comment memo="location" memo_size="small"][select name="laclocationintermediate" value="scalp/axillae/trunk/extremities NOT hands/feet=0|neck/hands/feet/external genitalia=10|face/ears/eyelids/nose/lips/mucous membranes=20"] - [comment memo="size" memo_size="small"][select name="lacsizeintermediate" value="2.5cm or less=1|2.6-7.5cm=2|7.6-12.5cm=4|12.6-20.0cm=5|20.1-30.0cm=6|30.1cm or greater=7"]
-CPT Code: [calc value="score=(laccomplexity)+(laclocationintermediate)+(lacsizeintermediate)" memo="calc'd value"][/conditional][conditional field="laccomplexity" condition="(laccomplexity).is('complex=13100')"] - [comment memo="location" memo_size="small"][select name="laclocationcomplex" value="trunk=0|scalp/arms/legs=20|face/ears/eyelids/nose/lips/mucous membranes=20|forehead/cheeks/chin/mouth/neck/axillae/genitalia/hands/feet=30|eyelids/nose/ears/lips=50"] - [comment memo="size" memo_size="small"][select name="lacsizecomplex" value="2.5cm or less=1|2.6-7.5cm=2|7.6-12.5cm=4|12.6-20.0cm=5|20.1-30.0cm=6|30.1cm or greater=7"]
-CPT Code: [calc value="score=(laccomplexity)+(laclocationcomplex)+(lacsizecomplex)" memo="calc'd value"][/conditional][conditional field="proctypeLaceration" condition="(proctypeLaceration).is('LACERATION REPAIR PROCEDURE NOTE')"]
ANESTHESIA AGENT(S): [checkbox value="Lidocaine 1% with epinephrine|Lidocaine 1% without epinephrine|Lidocaine 2% with epinephrine|Lidocaine 2% without epinephrine|Marcaine 0.5%|Bicarbonate buffering solution"]
-Total amt used: [text size="5"] ml, [text size="30" default="Lot# "]
[checkbox memo="Supervising Physician" name="LacRepairSup" value=""][/conditional][conditional field="LacRepairSup" condition="(LacRepairSup).is('')"]
SUPERVISING PHYSICIAN - Dr. [text size="20"]
[/conditional][conditional field="proctypeLaceration" condition="(proctypeLaceration).is('LACERATION REPAIR PROCEDURE NOTE')"]
[comment memo="type of consent (choose one)" memo_color="blue"][checkbox memo="verbal" memo_size="small" name="lacrepairconsenttypeverbal" value=""][checkbox memo="written" memo_size="small" name="lacrepairconsenttypewritten" value=""]
INDICATIONS/COUNSELING:
-Discussed reason and medical indication(s) for procedure which include(s): [checkbox value="improve hemostasis of wound|improve healing time of wound|prevent excess scarring to ensure optimal return of full function of affected area"]
-Discussed and patient demonstrated understanding of:
[checkbox value=" -limitations and risks of procedure
 -risk/likelihood of pain during/after procedure
 -risk/likelihood of bleeding during/after procedure
 -risk/likelihood of infection after procedure
 -risk/likelihood of scarring after procedure
 -complications from anesthesia/analgesia during/after procedure
 -possibility of repeat procedure needed"]
-Discussed alternatives to procedure which include: leaving wound to heal by secondary intent.
-Patient acknowledged understanding of the above items and desired to proceed.
[/conditional][conditional field="lacrepairconsenttypeverbal" condition="(lacrepairconsenttypeverbal).is('')"]-Patient consent and timeout were performed verbally in lieu of written consent due to: [checkbox value="austere medical conditions|high patient volume and unavailability of support staff to assist|unavailability of accessible/printed forms"]
-Patient made aware of above conditions preventing written consent and agreed to proceed.
-A time out was performed prior to the procedure ensuring:
[/conditional][conditional field="lacrepairconsenttypewritten" condition="(lacrepairconsenttypewritten).is('')"]-Confirmed that consent form appropriately signed and hardcopy to be scanned into patient's medical record.
-A time out was performed prior to the procedure and documented in a hardcopy form to be scanned into patient's record to include ensuring:
[/conditional][conditional field="proctypeLaceration" condition="(proctypeLaceration).is('LACERATION REPAIR PROCEDURE NOTE')"][comment memo="timeout
" memo_size="small"][checkbox value=" -Patient identified using full name and DOB.
 -Patient evaluated and medical record reviewed including history and lab/imaging findings if applicable.
 -Procedure and site/side matches the consent form.
 -Patient was involved in the site/side marking.
 -Confirmed with procedure team of:
  -correct patient, correct procedure, and correct site/side.
  -The patient has been positioned correctly for the procedure.
  -All necessary equipment are available.
  -Instrument sterility verified."]
  
PROCEDURE DETAILS:
-Wound cleansing was performed in usual fashion with [checkbox value="irrigation with tap water|irrigation with sterile saline|gentle scrub with soapy water|forceps removal of visible debris/foreign body"][checkbox memo="debridement" name="lacrepairdebridement" value=""][/conditional][conditional field="lacrepairdebridement" condition="(lacrepairdebridement).is('')"]
[textarea default="-Tissue debridement performed." rows="2" memo="description" memo_size="small" memo_color="orange"][/conditional][conditional field="proctypeLaceration" condition="(proctypeLaceration).is('LACERATION REPAIR PROCEDURE NOTE')"]
-Once wound determined sufficiently clean for closure, it was prepared and draped in usual fashion using [select value="|Betadine/Iodine|Chlorhexidine"] per manufacturer and infection control recommendations.
-Anesthetic approach was [select name="lacrepairanesthtechnique" value="|local/field block|digital block|regional block"]. [/conditional][conditional field="lacrepairanesthtechnique" condition="(lacrepairanesthtechnique).is('local/field block')"]The skin overlying the indentified lesion infiltrated with above anesthetic agent.
[/conditional][conditional field="lacrepairanesthtechnique" condition="(lacrepairanesthtechnique).is('digital block')"]Above anesthetic was used to perform block in usual fashion of [select value="R|L"] [select value="1st|2nd|3rd|4th|5th"] [select value="finger|toe"].
[/conditional][conditional field="lacrepairanesthtechnique" condition="(lacrepairanesthtechnique).is('regional block')"][textarea memo="description" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="laccomplexity" condition="(laccomplexity).is('intermediate=12030')||(laccomplexity).is('complex=13100')"]-Deeper wound closure was required to best reapproximate and prepare the wound for final closure. This was performed subdermally [select value="in running fashion|with single horizontal suture|single figure-of-eight stitch"] using [select value="3-0|4-0"] [select value="Vicryl|Monocryl|PDS"] suture material.
[/conditional][conditional field="proctypeLaceration" condition="(proctypeLaceration).is('LACERATION REPAIR PROCEDURE NOTE')"]-[/conditional][conditional field="laccomplexity" condition="(laccomplexity).is('intermediate=12030')||(laccomplexity).is('complex=13100')"]Final[/conditional][conditional field="laccomplexity" condition="(laccomplexity).is('simple=12000')"]Wound[/conditional][conditional field="proctypeLaceration" condition="(proctypeLaceration).is('LACERATION REPAIR PROCEDURE NOTE')"] closure was performed with [text size="3"] simple interrupted sutures using [select value="3-0|4-0|5-0|6-0"] [select value="Ethilon/nylon|Prolene/polypropylene|silk"] suture material.[checkbox memo="freetext comments about suturing" name="lacrepairsuturefreetext" value=""][/conditional][conditional field="lacrepairsuturefreetext" condition="(lacrepairsuturefreetext).is('')"]
[text default="-" size="80"]
[/conditional][conditional field="proctypeLaceration" condition="(proctypeLaceration).is('LACERATION REPAIR PROCEDURE NOTE')"][checkbox value="-EBL was less than 1ml and good hemostasis noted.
-Antibiotic ointment and a bandage were applied.
"][/conditional][conditional field="proctypeIncisionDrainage" condition="(proctypeIncisionDrainage).is('INCISION AND DRAINAGE PROCEDURE NOTE')"]

[checkbox name="abscessPE" value="PHYSICAL EXAM:"][/conditional][conditional field="abscessPE" condition="(abscessPE).is('PHYSICAL EXAM:')"]
-Lesion location - [select name="abscessexamlocation1" value="|Scalp|Face|Neck|Shoulder|Chest/Trunk|Abdomen|Buttocks|Inguinal|Male Genital Region|Female Genital Region|Arm|Elbow|Forearm|Wrist|Hand|Finger|Hip|Thigh|Knee|Leg|Ankle|Foot|Toe"][/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Scalp')"]- [select value="right|left|midline"] [select value="occipital|parietal|temporal|frontal|preauricular|postauricular"] area[/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Face')"]- [select value="right|left|midline"] [select value="preauricular|mandibular angle|cheek|nose|periorbital|perioral|chin|submandibular|submental"] area[/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Neck')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Shoulder')||(abscessexamlocation1).is('Elbow')||(abscessexamlocation1).is('Wrist')||(abscessexamlocation1).is('Hip')||(abscessexamlocation1).is('Knee')||(abscessexamlocation1).is('Ankle')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"] aspect[/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Arm')||(abscessexamlocation1).is('Forearm')||(abscessexamlocation1).is('Thigh')||(abscessexamlocation1).is('Leg')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Chest/Trunk')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Abdomen')"]- [select value="periumbilical|epigastrium|RUQ|LUQ|RLQ|LLQ"] aspect[/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Buttocks')"]- [select value="right|left|midline"] [select value="|medial|lateral"] [select value="perianal|gluteal cleft|cheek|gluteal fold"][/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Inguinal')"]- [select value="right|left"][/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Male Genital Region')"]- [select value="right|left|midline"] [select value="penile glans|penile shaft|base of penis|scrotum|periscrotal area"][/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Female Genital Region')"]- [select value="right|left|midline"] [select value="labia majora|labia minora|perilabial area|periclitoral area|mons pubis|perineum"][/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Hand')||(abscessexamlocation1).is('Finger')"]- [select value="right|left"], [checkbox value="palmar/volar|dorsal|medial|lateral"] aspect[/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Finger')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MCP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Foot')||(abscessexamlocation1).is('Toe')"]- [select value="right|left"], [checkbox value="plantar|dorsal|medial|lateral"] aspect[/conditional][conditional field="abscessexamlocation1" condition="(abscessexamlocation1).is('Toe')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MTP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="abscessPE" condition="(abscessPE).is('PHYSICAL EXAM:')"]
-Lesion size/diameter - [text size="8"] [select value="cm|mm"]
-Characteristics - [checkbox name="abscessPEchar" value="erythema|edema|induration|fluctuance|tenderness to palpation|drainage"][/conditional][conditional field="abscessPEchar" condition="(abscessPEchar).is('drainage')"]
- [checkbox value="purulent|serous|sanguinous/bloody"][/conditional][conditional field="proctypeIncisionDrainage" condition="(proctypeIncisionDrainage).is('INCISION AND DRAINAGE PROCEDURE NOTE')"]

PROCEDURE: ABSCESS INCISION AND DRAINAGE - [select name="InDproctype" value="|simple/single|complicated/multiple"]
CPT Code: [/conditional][conditional field="InDproctype" condition="(InDproctype).is('simple/single')"]10060[/conditional][conditional field="InDproctype" condition="(InDproctype).is('complicated/multiple')"]10061[/conditional][conditional field="proctypeIncisionDrainage" condition="(proctypeIncisionDrainage).is('INCISION AND DRAINAGE PROCEDURE NOTE')"][comment memo="
Select COMPLICATED for any of the following-
-Multiple incisions
-Drain placements
-Probing to break up loculations
-Extensive packing
-Subsequent wound closure
" memo_color="blue" memo_size="small"]
ANESTHESIA AGENT(S): [checkbox value="Lidocaine 1% with epinephrine|Lidocaine 1% without epinephrine|Lidocaine 2% with epinephrine|Lidocaine 2% without epinephrine|Marcaine 0.5%|Bicarbonate buffering solution"]
-Total amt used: [text size="5"] ml, [text size="30" default="Lot# "][checkbox memo="Supervising Physician" name="InDSup" value=""][/conditional][conditional field="InDSup" condition="(InDSup).is('')"]
SUPERVISING PHYSICIAN - Dr. [text size="20"]
[/conditional][conditional field="proctypeIncisionDrainage" condition="(proctypeIncisionDrainage).is('INCISION AND DRAINAGE PROCEDURE NOTE')"]
[comment memo="type of consent (choose one)" memo_color="blue"][checkbox memo="verbal" memo_size="small" name="InDconsenttypeverbal" value=""][checkbox memo="written" memo_size="small" name="InDconsenttypewritten" value=""]
INDICATIONS/COUNSELING:
-Discussed reason and medical indication(s) for procedure which include(s): [checkbox value="prevention of infection spread|reduced likelihood of requiring antibiotics|quicker resolution of abscess"]
-Discussed and patient demonstrated understanding of:
[checkbox value=" -limitations and risks of procedure
 -risk/likelihood of pain during/after procedure
 -risk/likelihood of bleeding during/after procedure
 -risk/likelihood of infection after procedure
 -risk/likelihood of scarring after procedure
 -complications from anesthesia/analgesia during/after procedure
 -possibility of repeat procedure needed"]
-Discussed alternatives to procedure which include: antibiotics and followup.
-Patient acknowledged understanding of the above items and desired to proceed.
[/conditional][conditional field="InDconsenttypeverbal" condition="(InDconsenttypeverbal).is('')"]-Patient consent and timeout were performed verbally in lieu of written consent due to: [checkbox value="austere medical conditions|high patient volume and unavailability of support staff to assist|unavailability of accessible/printed forms"]
-Patient made aware of above conditions preventing written consent and agreed to proceed.
-A time out was performed prior to the procedure ensuring:
[/conditional][conditional field="InDconsenttypewritten" condition="(InDconsenttypewritten).is('')"]-Confirmed that consent form appropriately signed and hardcopy to be scanned into patient's medical record.
-A time out was performed prior to the procedure and documented in a hardcopy form to be scanned into patient's record to include ensuring:
[/conditional][conditional field="proctypeIncisionDrainage" condition="(proctypeIncisionDrainage).is('INCISION AND DRAINAGE PROCEDURE NOTE')"][checkbox value=" -Patient was identified using full name and DOB.
 -Patient was evaluated and medical record reviewed including history and lab/imaging findings if applicable.
 -Procedure and site/side matches the consent form.
 -Patient was involved in the site/side marking.
"][checkbox value=" -For final timeout, physician paused or verbally confirmed with procedure team of:
  -correct patient, correct procedure, and correct site/side.
  -The patient has been positioned correctly for the procedure.
  -All necessary equipment are available.
"][checkbox value=" -Instrument sterility verified.
"]
PROCEDURE:
-The skin overlying/surrounding the indentified lesion was infiltrated with above anesthetic agent.
-Using [select value="#11|#15|#10"] blade scalpel, performed [text size="5"] [select value="cm|mm"] linear incision over lesion.
-Expressed/drained [select value="|mucopurulent|sanguinous/bloody"] material.
-Probed wound for loculations and [select value="no loculations found.|loculations were broken up with additional drainage."]
-Total amount of material drained: [text size="5"] ml
-Wound irrigated with [text size="5"] ml of [text size="25"].
-Wound packed with [select value="plain|iodoform"] ribbon gauze.
-Wound was overdressed in usual fashion.
[/conditional]
PATIENT DISPOSITION
[conditional field="proctypeLaceration" condition="(proctypeLaceration).is('LACERATION REPAIR PROCEDURE NOTE')"][textarea default="-Patient tolerated overall procedure well.
-No immediate complications noted.
-Discussed with patient return precautions to include: fever, erythema, swelling, pain, or purulent discharge from the wound.
-Post-procedure care of surgical wound discussed.
" rows="3"]
-Patient instructed to return for suture removal in [text size="5"] days.
[/conditional][conditional field="proctypeIncisionDrainage" condition="(proctypeIncisionDrainage).is('INCISION AND DRAINAGE PROCEDURE NOTE')"][textarea default="-Patient tolerated overall procedure well.
-No immediate complications noted.
-Discussed with patient return precautions to include: fever, progressive pain/swelling.
-Post-procedure care of surgical wound discussed." rows="3"]
-F/U in [text size="5"] day(s) for wound repacking
[/conditional]-Patient left in stable condition.
[textarea memo="additional comments" memo_size="small"]