Consent for the procedure is obtained after the patient expressed a full understanding of the risks and benefits of the procedure involved.
The would is cleaned and prepped in the usual fashion.
The wound is explored to its deepest surface. No foreign bodies or involvement of deeper structures or contamination was identified.
A total of [#] cc Lidocaine 1% was administered to the wound and surrounding tissue. Full anesthetization of the area was confirmed prior to the start of the procedure.
A total of [#] simple interrupted sutures using [SUTURE TYPE] were placed and wound edges were successfully approximated & eversion achieved without tissue strangulation.
During the procedure, there were no complications, and blood loss was negligible.
Bleeding is efficiently controlled. The patient tolerated the procedure well.
The post-procedure examination was unchanged and the patient is neurovascularly intact.
Ligament function distal to the wound is fully intact.
The wound was dressed in a thin layer of [Bacitracin] ointment and sterile gauze.
Wound care and follow-up were fully discussed with the patient.
The patient is instructed to RTC in [#] days. Will re-evaluate wound during next office visit for possible suture removal.
While infection of the sutured tissue is not expected, the patient was educated on S/S of infection (such as fever, redness/swelling/warmth/increased pain around the sutured site, any discharge that is not clear from the sutured site, or red streaks on the skin around the sutured site) and should RTC immediately for a wound check.
The patient verbalized and demonstrated an understanding of the information provided today.
The patient is discharged in a stable condition.
Assessment & Plan (long)
# [LOCATION] Laceration Repair
Location: [LOCATION]
Wound measurements: [#]
Consent for the procedure is obtained after the patient expressed a full understanding of the risks and benefits of the procedure involved.
The would is cleaned and prepped in the usual fashion.
The wound is explored to its deepest surface. No foreign bodies or involvement of deeper structures or contamination was identified.
A total of [#] cc Lidocaine 1% was administered to the wound and surrounding tissue. Full anesthetization of the area was confirmed prior to the start of the procedure.
A total of [#] simple interrupted sutures using [SUTURE TYPE] were placed and wound edges were successfully approximated & eversion achieved without tissue strangulation.
During the procedure, there were no complications, and blood loss was negligible.
Bleeding is efficiently controlled. The patient tolerated the procedure well.
The post-procedure examination was unchanged and the patient is neurovascularly intact.
Ligament function distal to the wound is fully intact.
The wound was dressed in a thin layer of [Bacitracin] ointment and sterile gauze.
Wound care and follow-up were fully discussed with the patient.
The patient is instructed to RTC in [#] days. Will re-evaluate wound during next office visit for possible suture removal.
While infection of the sutured tissue is not expected, the patient was educated on S/S of infection (such as fever, redness/swelling/warmth/increased pain around the sutured site, any discharge that is not clear from the sutured site, or red streaks on the skin around the sutured site) and should RTC immediately for a wound check.
The patient verbalized and demonstrated an understanding of the information provided today.
The patient is discharged in a stable condition.
Educational
You have received stitches today. Please read the following instructions so you know how to care for them:
Keep wound area dry for the first 24 hours.
Apply antibiotic ointment (i.e. Bacitracin) and a clean Band-Aid or sterile dressing daily for 48 hours. After 2 days, you may leave the sutures uncovered. May clean gently with mild soap and water OR 1/2 strength hydrogen peroxide, after 48 hours to prevent crusting over suture knots.
You may shower if your provider gives permission but do not take a bath until the skin is healed. Change the dressing after your shower.
Never leave a wet dressing or Band-Aid on your stitched as this allows bacteria to reach the area and may cause infection.
Watch for signs of infection:
Increasing redness, tenderness, or warmth around the suture site
Unsual swelling around the site
Appearance of pus around each suture or any red streaks
Fever
If you develop any of the above signs or symptoms of infection, please return to the clinic immediately to have your wound checked.
When sutures are removed depends on how well the wound is healing and where it is located. Sutures are usually removed from eyelids in 3 days; the face in 3-5 days; the torse in 7-10 days; the hands and feet in 7-10 days, and the scalp 7 days.
Return to the clinic to have your sutures removed. This can be done by any medical provider during regular hours on Monday through Friday.
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