Snider - Laceration Repair
A professional Emergency Medicine template for healthcare professionals.
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Chief Complaint
Medical Note Template -- Eye Complaint
CHIEF COMPLAINT
Laceration to: [part of body]
PMH
[Document the patient's primary laceration-related complaint, including cause, mechanism, intent, location of where injury occured. Also note when Tetanus was last updated]
Physical Exam
[Document location of the laceration, size, any other description of the laceration, whether it is well approximated and whether it will require suture, dermabond or other repair]
Procedure
Consent obtained. Risks and benefits discussed. Wound cleaned with chlorhexadine swab and anesthestized with [describe type of lidocaine used] Wound was irrigated [with normal saline and amount]. Wound was repaired using [number of sutures, type of sutures (e.g. 5.0 ethilon), type of suturing (e.g. simple interrupted) No complications noted. Wound dressed.
IMPRESSION AND PLAN
Laceration: [please summarize laceration and procedure] Plan: [Please summarize follow-up (e.g. Sutures out in number of days at family doctor, walk-in clinic, student clinic etc.)
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This comprehensive new patient template helps establish care by capturing complete medical history, current concerns, and baseline health status. Use this for patients during their initial visit to create a thorough medical record.
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