Dermatology & Wounds
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[date name="variable_1" default="08/03/2019"]
(S): CC: Head laceration
HPI: [text name="variable_1" default="age"] old [text name="variable_1" default="male/female"]was [text name="variable_1" default="history of injury"].
Laceration occurred at [text name="variable_1" default="time"].
Bleeding [select name="level of bleeding?" value="has ceased|is minimal|is profuse|is controlled|"]
Associated symptoms: [select name="associated symptoms?" 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_1" 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_1" default="level of distress"]
Skin: [text name="variable_1" default="cm"] long laceration to [text name="variable_1" default="location"]. Approximate depth [text name="variable_1" default="cm"].
Wound [text name="variable_1" default="description"]. Debridement [select name="debridement?" value="not required.|required.|"].
Underlying or nearby tendons: [select name="tendons?" value="none|intact|lacerated|"].
Neurovascular exam: [select name="NV status" 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_1" default="number"]cc of 2% Lidocaine [select name="epi?" value="WITH epinephrine|WITHOUT epinephrine|"]injected at the laceration site.
• [text name="variable_1" default="amount"]post-procedure bleeding.
• Skin cleansed well with NS solution
• [text name="variable_1" default="number of sutures"] x [select name="skin closure type" value="Steri-strips|Dermabond|3-0 non-absorbable sutures|4-0 non-absorbable sutures|5-0 non-absorbable sutures|6-0 non-absorbable sutures||"][var name="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"]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="timing of removal" 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 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, facein 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: