Laceration Repair Procedure Note Template

Laceration Repair Documentation Checklist. A good procedure note for a simple scalp repair might read. Wound and surrounding structures. Complete SOAP note for laceration repair. Laceration Note. Laceration Note. Patient tolerated procedure well. Suture Procedure Note. Wound packed with iodoform gauze. Procedure tolerated without complications. Wound dressed with sterile 4x4 guaze and paper tape.

Thanks to Super Scribes, James McAvoy and Tara Doyle for this fine work. Both have moved on to Medical School. Trdp Enhanced Program Benefits Booklet. Regina 2 De Octubre No Se Olvida Pdf on this page. How to Document Procedures Medication given to patient (A&P) • Medication • Dosage • Route • Time Ex) Ibuprofen 600 mg PO @ 1452 Zofran 4 mg SL @ 1743 Fluorescein Staining Eye (A&P) • Left, right or bilateral • Anesthetized • Whether or not corneal abrasion is seen • Use the provider’s description of the corneal abrasion Ex) 2 gtts of 2.5% Proparacaine placed in right eye. Right eye Fluorescein stained. Linear corneal abrasion seen at the 2 o’clock position with black light.