Skin/Soft Tissue Abscess Incision and Drainage Procedure Note

Date/Time: [Date and time of procedure]

Procedure: Skin/Soft Tissue Abscess Incision and Drainage

Anatomic Site and Laterality: [Anatomic site(s) and laterality]

Pre-Procedure Diagnosis: [Pre-procedure diagnosis]

Post-Procedure Diagnosis: [Post-procedure diagnosis]

Indication: [Clinical indication for I&D]

Operator(s): [Operator name(s) and role(s)]

Pre-Procedure Assessment

[Lesion description: size in cm and whether measured or estimated; presence or absence of fluctuance; tenderness; extent of surrounding erythema; presence or absence of spontaneous drainage.] [Relevant risk modifiers if present: immunocompromised state, diabetes, anticoagulation, recurrent abscess, proximity to neurovascular structures.] [Point-of-care ultrasound findings if performed: confirmation of abscess, depth, loculations.] (Document what supported the clinical diagnosis of abscess; do not infer abscess from erythema alone.)

Consent

Risks, benefits, and alternatives discussed; questions answered. Risks discussed included bleeding, pain, scarring, incomplete drainage with possible need for repeat procedure, and damage to surrounding structures. [Verbal / Written] consent obtained per facility policy. [If patient lacked capacity: Consent obtained from surrogate decision-maker, [name and relationship].]

Time-Out

Time-out performed with correct patient, procedure, and site/laterality verified.

Preparation and Anesthesia

Skin preparation: [Prep agent] using [clean / sterile] technique. Local anesthesia: [Agent] [concentration] [with / without] epinephrine, [volume] mL via [local infiltration / field block]. [Systemic analgesia if given: agent, dose, route.] (If no anesthesia used, state explicitly with reason.)

Procedure

(If multiple abscesses treated, repeat this section for each lesion with clear labeling.)

After appropriate preparation and anesthesia, an incision was made with [instrument]. [Incision orientation relative to skin tension lines if relevant.] Incision length: [length] cm. [Character of drainage: purulent / serosanguinous / other], [scant / moderate / large] amount, estimated [volume] mL. [Loculations disrupted using hemostat / blunt dissection / other, if performed.] [Irrigated with [solution] [volume] mL, if performed.] Hemostasis achieved with [method]. [Unexpected findings if any: foreign body, keratinous material suggestive of epidermoid cyst, cyst capsule noted and removed / deferred.]

Specimens

Wound culture: [obtained / not obtained]. [If obtained: [swab / aspirate] sent for [aerobic / anaerobic / gram stain / other].] [If not obtained: rationale, e.g., uncomplicated abscess, inflamed epidermoid cyst, per local protocol.]

Wound Management

Packing: [none / placed]. [If placed: [plain / iodoform] gauze, [width], external tail left.] [Loop drain if placed: material, size, fixation method.] Dressing: [dressing type] applied.

Post-Procedure

Complications: [None / describe]. [Estimated blood loss if clinically significant.] Patient [tolerated the procedure well / other]. [Post-procedure neurovascular status if procedure near extremity or at-risk structures.]

Antibiotics

[Antibiotics prescribed / No antibiotics prescribed]. [If prescribed: agent, dose, route, duration.] Rationale: [Patient-specific rationale, e.g., systemic symptoms, significant surrounding cellulitis, immunocompromised host, multiple or recurrent abscesses, extremes of age; OR adequately drained uncomplicated abscess without systemic symptoms.] (Always document decision with rationale.)

Disposition and Follow-Up

Disposition: [Discharged home / admitted / observation / other]. Follow-up: [Wound check timing and location, typically 24-48 hours if packing placed, large cavity, or high-risk patient.] [If culture obtained: plan for result notification and antibiotic adjustment if indicated.]

Return precautions: Worsening pain, fever or chills, spreading redness, increased drainage, recurrent swelling, red streaking.