Suture/Staple Removal Procedure Note

Date/Time: [Date and time of procedure]

Location: [Facility/department/room]

Performed by: [Name and credentials]

Procedure

Procedure performed: [suture removal / staple removal / both]
Anatomic site and laterality: [Specific site with laterality]
Indication: [Routine removal of sutures/staples placed on (date) for (procedure/repair description) / Early removal due to (reason) / Delayed removal due to (reason)]

Pre-Procedure Verification

(Include this section only when relevant; omit entirely for routine uncomplicated removals.)

• Patient identification confirmed; correct wound/site verified
• Consent: [verbal consent obtained / risks, alternatives, and purpose discussed for non-routine case]
• Time-out: [performed per facility policy / not required]

Pre-Removal Wound Assessment

(Use objective descriptors only. Document only findings that were actually assessed.)

• Approximation: [well-approximated / gapping / dehiscence]
• Erythema: [none / mild / moderate / spreading]
• Edema: [none / present]
• Warmth: [none / present]
• Tenderness: [none / present]
• Drainage: [none / serous / serosanguinous / purulent]; (If present, note amount: [scant / moderate / copious])
• Odor: [none / present]

Additional findings: [Surrounding skin integrity, bleeding, fluctuance, signs of cellulitis, patient-reported symptoms such as fever or increasing pain] (Include only if relevant.)

Removal decision: [proceeded with removal / partial removal / deferred]; (If partial or deferred, document reason and escalation actions.)

Removal Details

• Closure type: [interrupted sutures / running sutures / staples / mixed / unknown]
• Number removed: [#] (Required)
• Number remaining: [# remaining due to (reason)] (Include only if applicable.)
• Condition during removal: [intact / broken / embedded / overgrown]
• Technique: [Cleansed with (agent)]; [suture removal kit / staple remover]; [every-other removal performed for long incision] (Include relevant details.)
• Hemostasis: [none needed / minimal bleeding controlled with pressure / other intervention]
• Wound edge status after removal: [remains well-approximated / slight separation / gaping]
• Patient tolerance: [well tolerated / tolerated with discomfort / poorly tolerated / vasovagal symptoms]

Post-Removal Care

• Adhesive support: [Steri-Strips applied / not applied]
• Dressing: [left open to air / dry dressing / occlusive dressing]
• Immediate complications: [none / bleeding / wound separation / retained material / skin tear / vasovagal event]
• Post-procedure condition: [stable / observed and improved]

Instructions

Wound care instructions and return precautions reviewed.
Specific instructions: [Activity restrictions, wound protection, bathing precautions, or other patient-specific guidance] (Include only if unique to this patient.)
Follow-up: [routine PRN / re-check in (timeframe) / return for staged removal completion / earlier follow-up for borderline approximation]

(For routine uncomplicated cases, this note may be brief—the Pre-Procedure Verification section may be omitted and technique may be a single sentence. Always document the count of sutures/staples removed. If removal was partial or deferred, clearly document the reason and follow-up plan.)