Plastic Surgery Office/Bedside Procedure Note

Date/Time: [Date and time of procedure]

Location: [Clinic/bedside location and setting]

Patient: [Patient name and identifiers per policy]

Primary Operator: [Name, credentials]

Assistant(s): [Names/roles] (Include only if assistant present)

(Required fields: procedure name/site/laterality, indication, consent status, anesthesia used, key measurements for relevant procedures, complications, patient condition, and follow-up plan. Mark "unable to determine" with brief reason if required field cannot be completed. Omit optional fields entirely when not applicable. Never infer layered closure, debridement depth or area, absence of complications, or neurovascular status unless explicitly assessed.)

Procedure Summary

[Procedure(s) performed] — [Exact anatomic site and laterality] — [Indication/pre-procedure diagnosis]. [Post-procedure diagnosis if different]. (If multiple procedures or sites, list each separately.)

Pre-Procedure Assessment

(Document only procedure-relevant findings. Reference comprehensive H&P if it exists elsewhere rather than duplicating.)

• [Mechanism and timing of injury or onset] (Include for traumatic wounds)
• [Pertinent risk factors present: anticoagulation / diabetes / immunosuppression / smoking / bleeding disorder / keloid history] (List only those present)
• [Baseline exam relevant to site]
• [Laceration-specific: wound contamination status; suspected foreign body; suspected tendon/nerve/duct involvement; baseline distal neurovascular status]
• [Abscess-specific: size (cm), fluctuance, cellulitis extent]
• [Debridement-specific: tissue viability and wound bed quality]
• [Drain removal-specific: drain output trend and site condition]
• [Dressing change-specific: wound bed and periwound condition]

Safety Verification & Consent

(Omit this section only if institution documents time-out and consent in a separate standardized location; reference that location.)

• [Patient identity confirmed by: verbal confirmation / wristband / record check]
• [Procedure, site, and laterality verified; site marked: yes / no / not applicable per policy]
• [Allergies reviewed] (Note relevant allergies to local anesthetics, latex, prep solutions, or document no known allergies)
• [Time-out performed with participants]
• [Consent obtained: written / verbal] from [patient / surrogate]. Risks discussed: [bleeding / infection / scarring / poor cosmetic outcome / nerve injury / need for revision as applicable]. Alternatives including no procedure discussed. (If emergent exception, document rationale.)

Anesthesia

• [Type: none / topical / local infiltration / field block / digital block / regional block / moderate sedation]
• [Agent(s) and concentration; total volume (mL); site of administration]
• [Adequacy and patient tolerance]

(If moderate sedation used, reference the dedicated sedation record for medication timing, monitoring, and recovery.)

Procedure Details

Preparation

[Patient position]. [Skin prep solution]. [Sterile technique/draping as applicable].

Findings

[Wound/lesion characteristics and tissue viability; abscess contents and character if present; foreign material identified; exposure of deeper structures; dead space]

Technique

(Provide a chronological narrative of key steps including instruments used, irrigation solution and volume when applicable, hemostasis methods, and closure/wound management approach. Include only relevant procedure subsections below.)

Laceration Repair

(Document each wound separately.)

• Wound [#]: [Exact anatomic location and laterality]; [Length after closure (cm)]; [Depth/structures involved: epidermis / dermis / subcutaneous / fascia / cartilage]; [Wound contamination level]
• [Exploration findings: foreign body, tendon, nerve, duct involvement; hemostasis status]
• [Irrigation: solution and volume (mL)]
• [Debridement of devitalized edges: yes/no; instrument if yes]
• [Undermining: yes/no; extent (cm) if yes]
• [Closure details by layer: e.g., deep dermal (suture type/size, pattern); skin (suture type/size, pattern); adhesive/strips if used] (Document only what was performed)
• [Alignment of key landmarks: vermilion border / eyelid margin / other] (Include when relevant)

Incision & Drainage

• [Incision type and length (cm); instrument]
• [Drainage character and approximate amount]
• [Loculations broken up: yes / no]
• [Irrigation: solution and volume (mL)]
• [Packing material and placement] or [Drain placed: type and size]
• [Culture sent: yes / no]

Sharp Debridement

(Document each wound separately. Measurements are critical for coding.)

• Wound [#] pre-debridement: [Length × Width × Depth (cm)]
• [Tissue type removed: eschar / slough / devitalized subcutaneous / nonviable fascia / other]
• [Depth of tissue debrided: epidermis-dermis / subcutaneous / fascia-muscle / bone]
• [Instrument(s) used]
• [Area debrided (cm²)]
• Post-debridement: [Length × Width × Depth (cm)]

Drain Removal

• [Drain type and site]
• [Indication for removal]
• [Removal technique; removed intact: yes / no]
• [Site care and dressing applied]

Dressing Change

• [Indication]
• [Old dressing removal findings: granulation vs slough; exudate character; periwound condition; tunneling/undermining]
• [Cleansing/irrigation performed]
• [Topicals applied]
• [Packing details if applicable]
• [Final dressing layers]

Specimens/Cultures

[Item(s) sent, labeled source, and destination] (If none, state "None sent.")

EBL

[Estimated blood loss: mL or minimal]

Complications

[Complications and management] or [None] (Do not assume; explicitly document)

Post-Procedure Condition & Plan

• [Patient tolerance and immediate post-procedure condition]
• [Post-procedure exam: hemostasis achieved; neurovascular status distal to site when relevant]
• [Disposition: home / observation / ED / other]
• [Wound care instructions provided]
• [Follow-up timing for wound check and/or suture removal]
• [Return precautions reviewed: bleeding, fever, increasing pain, spreading redness, purulent drainage, wound separation, new numbness or weakness]