Wound/Laceration Repair Procedure Note

Date/Time of Procedure: [start time; end time optional]

Location: [ED / UC / clinic / bedside]

Operator: [name, credentials]

Procedure: [simple laceration repair / intermediate layered closure / complex repair]

Anatomic Site: [precise location with laterality] (Required for coding.)

Indication & Pre-procedure Assessment

[Indication and pre-procedure summary] (Briefly describe the indication, mechanism of injury, time since injury, and relevant allergies—especially to local anesthetics, antiseptics, or adhesives. Note any high-risk features such as heavy contamination, bite wound, devitalized tissue, immunocompromise, or suspected foreign body.)

Wound Assessment

Location: [precise anatomic description with laterality]

Length: [__ cm] (Required for coding.)

Depth/Layers: [skin only / subcutaneous / fascia / muscle / tendon / cartilage / bone / joint involvement]

Contamination: [clean / contaminated—describe contaminant]

Devitalized Tissue: [present—describe extent / absent]

Neurovascular/Tendon Assessment: [distal perfusion, sensation, motor function, ROM testing as applicable to site] (If neurovascular, tendon, or joint involvement requires consultation or transfer, document reason and disposition.)

Foreign Body Evaluation: [explored through full depth—findings] [imaging obtained—results / imaging not obtained—rationale]

(For multiple wounds, repeat this Wound Assessment subsection for each additional wound.)

Consent & Safety

Consent: [obtained from patient / obtained from guardian / not obtained—reason]; [verbal / written]; risks discussed including infection, scarring, wound dehiscence, and retained foreign body; alternatives reviewed; questions answered. (Do not infer; only include if consent was addressed.)

Time-out: [performed confirming correct patient, procedure, and site] (Only include if performed; do not infer.)

Anesthesia

Method: [local infiltration / digital block / regional block / topical]

Agent: [name, concentration, dose/volume] (If recorded in medication administration record: "See MAR for administered doses.")

Epinephrine: [yes / no]

Wound Preparation & Management

Skin Prep: [agent used]

Irrigation: [solution, method, volume in mL] (Use "copious" only if volume not tracked.)

Exploration: [explored through full depth; explored through ROM if near tendons/joints; findings including foreign body present/absent]

Debridement: [none / sharp / blunt—describe type and extent] (Include only if performed.)

Hemostasis: [direct pressure / epinephrine / electrocautery / hemostatic agent / vessel ligation / other]

(For multiple wounds, repeat this subsection for each additional wound.)

Closure Details

Closure Decision: [primary closure / delayed primary closure / left open—reason]

Repair Classification: [simple / intermediate / complex]

Layers Closed: [skin only / deep dermal and skin / fascia / other—specify]

Technique: [simple interrupted / running / vertical mattress / horizontal mattress / subcuticular / staples / tissue adhesive / adhesive strips] (For tissue adhesive, document that edges were approximated and adhesive applied in layers.)

Suture/Staple/Adhesive: [material, size, approximate count]

Deep Sutures: [material, size, count, layer] (Include only if applicable.)

Final Length: [__ cm] (Measured after closure.)

Alignment Notes: [alignment of key landmarks if relevant—vermilion border, eyebrow, nail fold] (Include only if applicable.)

(For multiple wounds, repeat this subsection for each wound, documenting site, length, depth, contamination status, closure type, complexity, and materials separately.)

Dressing & Immobilization

Dressing: [dressing applied] (Omit this section if only a simple adhesive bandage was used.)

Splint: [type, joint position, post-splint neurovascular status] (Include only if performed.)

Post-procedure Assessment

Hemostasis: [confirmed at completion / ongoing bleeding—describe]

Post-procedure Neurovascular Status: [perfusion, sensation, motor as relevant to site]

Complications: [none / describe] (Do not infer; only include if explicitly confirmed.)

Tolerance: [tolerated well / concerns—describe]

Medications & Prophylaxis

Tetanus: immunization [up-to-date / out-of-date / unknown]; [Tdap given / Td given / TIG given / not indicated—reason] (If status unknown, document action taken.)

Antibiotics: [not indicated—uncomplicated clean wound / indicated due to ___; prescribed ___ for ___ days] (Do not document antibiotics as "for tetanus prevention.")

Analgesia: [agent and duration] (Include only if prescribing beyond OTC.)

Discharge Plan

Wound Care Instructions: provided [key points—dressing changes, clean and dry vs moist healing approach]

Return Precautions: discussed [fever, increasing redness/swelling, purulent drainage, worsening pain, wound separation, numbness/weakness]

Suture/Staple Removal: [timeframe in days / per specialist follow-up]

Follow-up: [when/where; specialist referral if needed]

Activity Restrictions: [restrictions if applicable] (Omit if none.)