Laceration Repair Procedure Note

Date/Time: [Date and time of procedure]

Procedure: Laceration Repair

Location: [ED / clinic / procedure room / bedside]

Proceduralist: [Name, credential]

(Only include sections or fields with information explicitly documented. Do not invent or infer findings. For Complications, default to "None" if not mentioned. Tetanus Prophylaxis is required; prompt for details if not addressed. Do not infer neurovascular status or tendon integrity unless explicitly assessed. For multiple lacerations, create a separate numbered entry under Repair Details for each wound.)

Indication

[Brief statement of medical necessity for repair with pre-procedure diagnosis and body site] (If diagnosis changes after exploration, add post-procedure diagnosis.)

Pertinent History

[Time since injury]. [Mechanism of injury]. [Contamination status]. [Foreign body concern if any]. [Relevant bleeding risk factors or allergies]. [Tetanus history if not documented in Tetanus Prophylaxis section.]

(Omit this section if no additional pertinent procedural history beyond the main encounter note.)

Pre-Procedure Assessment

Wound inspection: [Anatomic location with laterality and landmarks], length [X] cm, depth [superficial / through dermis / into subcutaneous tissue / to fascia], wound edges [clean / stellate / avulsed / ragged], [contamination or devitalized tissue if present].

Neurovascular and functional assessment: [Perfusion, motor function, and sensation findings] (Include for wounds on extremities, hands, feet, face, or near tendons/nerves. If exam limited, document what was attempted, limitations, and plan.)

Foreign body evaluation: [Visualization/exploration findings and any imaging with results] (Include only if foreign body concern.)

Consent

Informed consent obtained from [patient / parent or guardian / surrogate], [verbal / written]. Risks (pain, bleeding, infection, scarring, poor cosmesis, need for revision), benefits, and alternatives discussed; questions answered. Pre-procedure verification performed. (If treated under emergency exception, document circumstances.)

Anesthesia

[Topical / local infiltration / field block / digital nerve block / regional nerve block], [agent and concentration], [X] mL total volume. [Technique notes if relevant]. Complications: [none / describe]. (If no anesthesia used, document rationale and pain management approach.)

Wound Preparation

Skin cleansed with [cleansing agent], [sterile / clean] technique. Hemostasis achieved with [direct pressure / epinephrine / tourniquet / cautery / none required]. Irrigated with [solution], [X] mL. Exploration: [explored to base, no foreign body, no exposed deeper structures / findings if abnormal]. Debridement: [none / describe extent and tissue removed].

Repair Details

(For multiple wounds, create a separate numbered subsection for each wound.)

Wound #1

Location: [Anatomic site with laterality and landmarks]. Length: [X] cm. Depth: [superficial / through dermis / into subcutaneous tissue / to fascia].

Repair type: [Simple single-layer / layered / complex]. Closure: [Sutures / staples / tissue adhesive / combination]; [materials and sizes per layer]; [technique]; [number of skin sutures or staples].

Result: [Well-approximated / mild tension], hemostasis achieved. [Reinforcement with Steri-Strips if used.]

Wound #2

(Repeat format for each additional wound.)

Total repaired length: [Total cm grouped by anatomic region and complexity] (Include only if multiple wounds.)

Post-Procedure Assessment

Neurovascular status: [Unchanged from pre-procedure / describe any changes] (Include for anatomically relevant wounds.)

Dressing: [Topical ointment if used], [dressing type and layers].

Immobilization: [None / splint type and joint position / sling]; neurovascular status after application [intact / describe]. (Include only if immobilization applied.)

Patient tolerance: [Tolerated well / describe any issues].

Complications

[None / describe: continued bleeding, suspected retained foreign body, anesthesia reaction, wound dehiscence, other]. [Estimated blood loss and foreign body disposition if clinically significant.] (Default to "None" if not otherwise documented.)

Tetanus Prophylaxis

Wound category: [clean and minor / dirty or tetanus-prone]. Vaccination history: [up to date / incomplete / unknown], last vaccine [date if known]. Action: [Tdap / Td given, dose, route, site / TIG given / vaccine declined with counseling / deferred with plan / up to date, none indicated]. (This section is required.)

Disposition and Follow-Up

Wound care instructions and return precautions reviewed with [patient / caregiver]: dressing care, bathing instructions, activity restrictions, follow-up for wound check and [suture / staple] removal in [X] days, and signs requiring return (infection, bleeding, worsening pain, numbness, weakness, dehiscence). [Medications prescribed: agent, indication.] (Reference discharge paperwork if detailed instructions documented there.)