Laceration repair

Laceration Repair
Date/Time: []
Indication:  Laceration as described above
Provider: Self
Layers: [1]
Complexity: [complex]
The appropriate timeout was taken. Verbal consent was obtained. The area was prepped and draped in the usual sterile fashion. Local anesthesia was achieved using [5]cc of 1% lidocaine with epinephrine. The wound was copiously irrigated with 100ml/cm of normal saline.  [3 4-0 nylon] sutures were placed. Hemostasis was achieved. The wound was dressed with a non-adherant dressing. There were no complications and the patient tolerated the procedure well. Post-procedurally the area was re-examined and distal/surrounding sensation, motor, and vasculature was unchanged from pre-procedure exam, taking into account expected sensation changes from the local anesthetic. 
EBL < 10mL
Total Time for Procedure: 15 mins

Charting Tips

  • Each separate laceration qualifies for an individual repair note. If you repair three different lacs then do three different notes. This note is designed to be ambiguous enough to simply label the name as “Laceration Repair #x” and adjust the length as needed. 
  • Under “complexity” it is important to specify qualitative factors such as simple, complex, etc…