Ingrown Toenail Procedure Note (Partial Nail Avulsion)

Date/Time: [Date and time of procedure]

Location: [Clinic/procedure room/bedside]

Clinician: [Name, credentials]

Patient: [Name and identifiers per organizational policy]

Procedure Identification

Procedure: [partial nail avulsion / complete nail avulsion / other specific procedure name]

Indication: [ingrown toenail / onychocryptosis / paronychia / recurrent ingrown nail / other]

Laterality: [right / left]

Digit: [great toe/hallux / 2nd toe / 3rd toe / 4th toe / 5th toe]

Border: [lateral / medial / both]

Extent: [partial (approximate percentage) / complete nail plate]

Matrix Treatment Planned: [no matrixectomy planned / matrixectomy planned: [phenol / sodium hydroxide / electrocautery / surgical matrix excision]]

(If laterality, digit, or border cannot be verified, document that the procedure was deferred until verification and do not complete subsequent sections.)

Pre-Procedure

• Focused safety assessment
  • Allergies: [local anesthetics / antiseptics (iodine/chlorhexidine) / latex / none / other]
  • Bleeding risk: [anticoagulants / antiplatelets / bleeding disorders / none]
  • Vascular/neuropathy/immunosuppression: [diabetes / PAD / neuropathy / immunosuppression / none] (Include only if applicable)
• Local findings: [cellulitis / abscess / purulence / granulation tissue / none] (Describe location and extent if present)
• Baseline neurovascular exam (pre-anesthesia):
  • Capillary refill: [seconds]
  • Perfusion: [skin temperature, color findings]
  • Sensation: [findings to light touch/pinprick]
• Consent:
  • Consented by: [patient / surrogate (relationship)]
  • Capacity: [confirmed / not applicable]
  • Risks discussed: [pain, bleeding, infection, recurrence, nail deformity, anesthetic reaction]
  • Benefits and alternatives discussed: [conservative care, observation, alternate procedural approaches]
  • Questions addressed: [yes / no]
  • Consent obtained: [verbal / written]

Time-Out

• Verification of correct patient, correct procedure, and correct laterality/digit/border completed immediately prior to procedure.
• Participants: [names/roles of those confirming]
• Site marking: [performed / not required per policy; verbal verification of laterality/digit/border completed]

Anesthesia

• Technique: [digital nerve block / local infiltration / none (rationale)]
• Agent and concentration: [lidocaine 1% / lidocaine 2% / bupivacaine 0.25% / bupivacaine 0.5%] [with epinephrine / without epinephrine]
• Volume: [total mL]
• Pre-existing neurologic deficits before block: [none / describe]
• Onset confirmed: [yes, sensory testing method] / [no]
• Complications: [none / describe event and management]

Procedure Details

• Positioning: [supine / seated / other]
• Skin preparation: [chlorhexidine / povidone-iodine / other]; Technique: [clean / sterile]; Draping: [applied / not applied]
• Tourniquet: [type and placement; time on; time off] (Only include if used)
• Nail plate elevation: [instrument used, approach described]
• Longitudinal split (for partial avulsion): [instrument used, direction, width]
• Nail segment removal: [traction direction]; Segment removed intact: [yes / no]; Additional fragments removed: [yes / no, describe if present]
• Inspection: [no retained spicule under proximal nail fold or lateral sulcus / retained fragment identified and removed]
• Soft tissue management (if applicable): [granulation tissue / paronychia] treated via [curettage / excision / cautery]; rationale: [hemostasis / reduce recurrence / other]

(Document key steps performed; avoid generic phrasing such as "performed in usual fashion.")

Matrix Ablation

(Include this section only if matrixectomy/matrix ablation was performed.)

• Method: [phenol / sodium hydroxide / electrocautery / surgical matrix excision]
• Chemical application details (if applicable): [concentration]; [number of applications]; [duration per application]; Neutralization/irrigation: [performed, describe / not performed]
• Area treated: [lateral horn / medial horn / bilateral]
• Precautions: [skin protection measures, isolation of matrix, irrigation]

No matrixectomy/matrix ablation performed. (Include this explicit statement only when matrixectomy was not performed.)

Hemostasis and Dressing

• Hemostasis: [direct pressure / chemical cautery (silver nitrate) / electrocautery]
• Estimated blood loss: [minimal / quantify if significant]
• Dressing:
  • Topical: [petrolatum / antibiotic ointment / none (rationale)]
  • Primary dressing: [non-adherent gauze / petrolatum gauze / other]
  • Secondary dressing: [gauze wrap / cohesive bandage / other]
  • Footwear recommendation: [post-op shoe / open-toe shoe / routine footwear]

Post-Procedure Status

• Patient tolerance: [tolerated well / tolerated poorly, describe]
• Immediate complications: [none / describe and management]
• Post-procedure neurovascular check: Capillary refill: [findings]; Sensation: [findings]; Perfusion: [findings]

Specimens/Cultures

(Include this section only if specimens were sent to pathology or cultures obtained.)

• Specimen/culture obtained: [nail plate / tissue / drainage swab / other]
• Rationale: [evaluate infection / rule out onychomycosis / other]
• Destination: [pathology / microbiology]

Medications

(Include only if procedure-related medications were prescribed.)

• Analgesia: [agent, dose, frequency, duration]
• Antibiotics (if indicated): [agent, dose, frequency, duration]; Indication: [cellulitis / abscess / immunosuppression risk / other]

Follow-Up

• Timing and purpose: [return in specified timeframe for wound check / suture removal / PRN / phone follow-up]
• When to seek urgent care: [increasing pain, uncontrolled bleeding, spreading redness, fever, signs of ischemia, purulent drainage]
• Referral plan: [podiatry / dermatology / vascular surgery / none] (Include if recurrence, severe deformity, or vascular concerns)

(Omit non-applicable sections such as Specimens/Cultures or Medications. Ensure all required identifiers—laterality, digit, border, extent, and matrixectomy status—are explicitly documented.)