Facial Laceration Repair Procedure Note

Procedure: Facial Laceration Repair

Date/Time: [Date] [Start time] [End time if sedation used or procedure prolonged]

Location: [ED / clinic / urgent care / OR bedside]

Operator: [Name and role]

Indication

[Pre-procedure diagnosis and mechanism if relevant to contamination or foreign body risk]; [anatomic site(s) with laterality]; [complexity: simple / layered anticipated]; [special features: vermilion border involvement / through-and-through oral-cutaneous / bite / contaminated / avulsion / none]. (If multiple wounds, identify each as Wound #1, Wound #2, etc.)

Relevant History

[Time since injury in hours]; [tetanus status: date of last vaccine / unknown - registry checked]; [relevant allergies to local anesthetics, antiseptics, or antibiotics]; [anticoagulant/antiplatelet use or bleeding disorder]; [infection risk factors: diabetes / immunocompromise / none]. (Include only when clinically relevant. If safety-critical information is unknown, document as "unknown" with mitigation steps taken.)

Pre-Procedure Examination

• Wound description: [Precise anatomic location with laterality], [length in cm], [estimated depth], [shape: linear / stellate / flap / avulsion], [contamination: none / minimal / gross - specify type], [tissue viability], [active bleeding: none / minimal / ongoing].
• Neurovascular/functional exam: [Facial motor function and symmetry], [sensation in relevant distributions], [perfusion/capillary refill], [intraoral findings if applicable: mucosal involvement / dental injury / occlusion].
• Exam limitations: [None / limited due to pain, agitation, or other reason with plan to address].
• Red flags for consultation: [None / suspected duct or canalicular injury / eyelid margin involvement / deep structural injury / uncontrolled hemorrhage]. (If present, document specialty consult obtained.)

Imaging

[Not indicated - reason / Obtained: modality and relevant findings / Deferred - reason]. [Foreign body suspicion: low / moderate / high - assessment basis].

Consent

[Verbal / written] consent obtained from [patient / guardian]. Risks discussed: pain, bleeding, infection, scarring, poor cosmetic outcome, wound dehiscence, retained foreign body, nerve injury, possible need for revision. [Interpreter used: yes / no / not required]. (If any component refused, document counseling provided and patient decision.)

Time-Out

[Correct patient, procedure, and site/laterality verified immediately before starting / Not performed - reason and mitigation].

Anesthesia

• Topical: [Agent], [site], [duration]. (Include if used.)
• Local infiltration: [Agent], [concentration], [total volume in mL], [with / without epinephrine].
• Nerve block: [Block name: infraorbital / mental / supraorbital / supratrochlear / other], [laterality], [agent], [volume in mL]. (Include if performed.)
• Procedural sedation: [See separate sedation record]; [intended level], [monitoring personnel], [key medications]. (If standard monitoring limited due to facial access, document what was and was not possible.)

(If no anesthesia used, document "No anesthesia required" with reason.)

Preparation

[Positioning and lighting]; [skin/mucosal prep agent with note of limitations near eyes or mucosa]; [sterile / clean field per local protocol]; [sterile instruments confirmed].

Procedure

Exploration: [Depth explored], [method used], [foreign body search performed - findings and items removed if any], [deeper structures visualized or injured: cartilage / muscle / nerve / duct / none].

Irrigation: [Solution type], [total volume in mL], [delivery method and pressure: syringe with gauge / faucet / bulb syringe].

Debridement: [No debridement required / conservative / extensive]; [tissue debrided: devitalized edges / contaminants / specify].

Hemostasis: [Method(s): direct pressure / cautery / ligation / topical agents / suture]; [estimated blood loss if more than minimal].

Closure

(Document each wound separately. Wound length, anatomic location, and layers closed are required for billing.)

Wound #1

• Location/laterality: [Anatomic location and side].
• Length: [Length in cm].
• Closure classification: [Single-layer / layered]; [complex features: undermining / tissue rearrangement / none].

Layer-by-layer closure (include only layers actually repaired):

• Mucosa: [Suture material], [size], [technique], [stitch count]. (If intraoral component.)
• Muscle: [Suture material], [size], [technique], [stitch count]. (If repaired.)
• Deep dermal/subcutaneous: [Suture material], [size], [technique], [stitch count].
• Skin/epidermis: [Suture material / adhesive / strips], [size if suture], [technique], [stitch count].

Landmark alignment: [Vermilion border / eyebrow / philtrum / nasal ala / eyelid margin / not applicable]; [alignment technique]; [key alignment suture placed first: yes / no]. (Include if anatomic landmark involved.)

Approximation quality: [Edge eversion: achieved / partial / not achieved]; [tension: low / moderate / high]; [dead space eliminated: yes / no]; [gaps or planned delayed closure: none / specify].

Dressing: [Topical agent: petrolatum / antibiotic ointment / none]; [dressing type].

Wound #2

(Add if applicable; repeat same fields: location/laterality, length, closure classification, layer-by-layer details, landmark alignment, approximation quality, dressing.)

Post-Procedure Assessment

[Patient tolerance: tolerated well / poorly - specify]; [hemostasis confirmed]; [post-repair motor and sensory exam if relevant]; [complications: none / specify]; [photos taken: yes - storage location / no].

Tetanus and Antibiotics

• Tetanus: [Wound category: clean-minor / dirty-major]; [vaccine indicated: yes / no - reasoning]; [product: Tdap / Td], [site]; [TIG: given / not indicated].
• Antibiotics: [Indication: bite / through-and-through oral / gross contamination / cartilage involvement / immunocompromise / none]; [drug, dose, route, duration if prescribed / not indicated - reasoning].

Discharge Planning

Verbal and written wound care instructions provided. [Suture removal: specific return date range, noting facial sutures typically 5-7 days]; [absorbable suture expectations if used externally]; [follow-up with: PCP / urgent care / plastics / ENT / ophthalmology / wound check in ED]; [return precautions reviewed: increasing pain, redness, swelling, fever, wound opening, bleeding, new numbness or weakness].

(Meta: Wound length, anatomic location with laterality, and layers closed must be documented for each wound. Capture suture material, size, and stitch count per layer; if unavailable, note "not recorded at time of repair." If examination or procedural steps were limited or omitted, document reason. If tetanus status, allergies, or anticoagulant use unknown, document as unknown with actions taken. If patient refused imaging, tetanus, or antibiotics, document counseling and decision.)