Nail Matrixectomy Procedure Note

Date: [Date of procedure]

Clinician: [Name and credentials of performing clinician]

Location: [Clinic/site name]

Procedure Summary

[REQUIRED: Single-line summary including exact site and method] (Format: [Right/Left] [digit] [medial/lateral/both borders] [partial/total] nail avulsion with [chemical/surgical/electrocautery] matrixectomy. Example: "Right hallux lateral border partial nail avulsion with chemical matrixectomy (phenol)." Do not infer laterality, digit, or border.)

Indication

[Primary indication, duration and severity of symptoms, functional impact, prior conservative treatments and response, current infection status, relevant comorbidities if applicable] (Write as a brief narrative establishing medical necessity. Include primary diagnosis, chronicity, effect on ambulation/footwear, failed conservative measures such as soaks, footwear modification, prior avulsions, or antibiotics. State infection status explicitly. Note diabetes, PVD, immunosuppression, or anticoagulation only if present. If recurrence history is uncertain, document the uncertainty rather than inferring.)

Pre-Procedure Assessment

• Allergies: [Relevant allergies] (Local anesthetics, antiseptics, adhesives; include reaction type if known.)
• Anticoagulation: [Current anticoagulant/antiplatelet therapy or none]
• Toe examination: [Involved border, granulation tissue, erythema, swelling, drainage, neurovascular status]

Informed Consent

[REQUIRED: Consent documentation] (Document method [written/verbal per policy], that procedure and alternatives were explained, and material risks reviewed: infection, bleeding, pain, delayed healing, recurrence/spicule formation, cosmetic change/narrowed nail, chemical burn if applicable, anesthetic reaction. Alternatives discussed: conservative care, simple avulsion without matrixectomy, referral. State patient agreement. If consent status is unknown, insert hard-stop placeholder requiring completion before finalization.)

Time-Out Verification

[Time-out completed] (Confirm: correct patient identity using two identifiers, correct procedure, correct site confirmed matching consent and marking, allergies reviewed, equipment and chemicals available and labeled.)

Anesthesia

• Type: [REQUIRED: Digital block / local infiltration / none with rationale]
• Medication: [REQUIRED: Agent name and concentration]
• Dose: [REQUIRED: Total volume in mL and/or total dose in mg]
• Technique: [Anatomic approach for block/infiltration]
• Adequate anesthesia confirmed: [REQUIRED: Yes, prior to procedure]

Tourniquet

[Tourniquet: not used / used] (If not used, state explicitly. If used, document: type, placement location, time applied, time released, total duration in minutes. For pneumatic tourniquet, include pressure setting.)

Procedure Details

[REQUIRED: Chronological narrative of procedure] (Write as a concise paragraph. Include: site confirmation restating laterality/digit/border, skin prep and sterile technique, partial vs total nail avulsion with separation and removal technique, and matrixectomy method with specific parameters. For chemical matrixectomy: agent, application method, number of applications, duration of each, irrigation/neutralization solution. For surgical matrixectomy: extent of excision, lateral horn addressed, hemostasis method. Also include: irrigation, hemostasis achieved, tourniquet release with perfusion assessment if applicable, and final inspection confirming complete matrix destruction and absence of residual nail spicules. Do not infer method or parameters.)

Complications and Tolerance

Complications: [REQUIRED: None / specific complications with management] (Do not leave blank or omit. Document any events: chemical burn, vasovagal episode, uncontrolled bleeding, anesthetic reaction.)

Patient tolerance: [Well tolerated / discomfort controlled / procedure terminated early with reason]

Dressing Applied

[Topical agent, dressing layers, post-operative shoe] (Document: topical agent applied such as antibiotic ointment or petroleum-based product, dressing components including non-adherent layer, gauze, tube gauze or wrap, and whether post-operative shoe was provided.)

Post-Procedure Instructions

• Activity: [Rest, elevation, weight-bearing instructions]
• Dressing changes: [Timing of first change and frequency]
• Wound care: [Cleansing or soaking protocol if recommended]
• Pain management: [OTC recommendations and when to call for worsening pain]
• Expected course: [Anticipated drainage and healing timeline]
• Warning signs: [Signs requiring prompt evaluation: increasing redness, warmth, purulent drainage, fever, streaking, uncontrolled bleeding, severe pain, numbness]
• Antibiotics: [Prescribed with name/dose/duration / not prescribed with criteria for contacting clinic]
• Follow-up: [Timing and purpose]
• Written aftercare instructions provided and reviewed: [Yes / No]

Disposition

[Condition at discharge and follow-up plan] (Include: stable/ambulatory/pain controlled; appointment scheduled on date or patient to schedule.)