Demographic Data:

Patient Name: Mr. Mango Smith MRN 80808080 DOB: 7/23/1978

Date: 10/9/20 Time: 13:45

Location: ER bay #6

Procedure: Laceration repair

Indication: Suture due to laceration on palmar aspect of right hand.

Provider: James Harrison, PA-C

Allergies: Pollen Reaction: Severe skin rash

Consent:

Discussed with patient the need for suturing the laceration on his hand. Discussed with patient the
complications that could arise from not performing this procedure which include increased healing time,
increased infections, worse cosmetic outcome and increased scar tissue. Talked to patient about the
complications that could potentially arise from this procedure. These complications included infection,
scaring, loss of function and structure, loss of cosmetic appearance and wound dehiscence. Written
consent was obtained by the patient and witnessed by RN before the procedure was performed.

Pertinent Diagnostic Data: none

Anesthesia: 1% lidocaine was used to perform a field block

Relevant exam: Patient presented with a piece of glass penetrating the palmar surface of the right
hand. After removal, a physical exam was performed to assess for any other foreign bodies within the
laceration. Slight bleeding was noted. Vital signs were obtained to ensure patient was stable and ready
for suturing. The patient’s tetanus history was obtained and is up to date.

Description of the procedure: Patient was instructed to place his hand over the examination table and
was draped. The laceration was examined for debris and dried blood. Local anesthesia 1% lidocaine was
injected to the field around the laceration. Non absorbable Prolene (Nylon) 5-0 was used for this
procedure. Once a sterile field was obtained, the skin was prepped with chlorhexidine. A simple
interrupted suture was used to close the laceration, and the skin was everted accordingly. A total of 6
sutures were placed on the skin, with equal widths and depths. The sutures were 1cm apart and 0.5cm
in width on both sides. After suturing, an antibiotic ointment- Bacitracin was used to coat the sutured
laceration and a non-adhesive gauze dressing was placed on the wound.

Findings: Erythema noted around the laceration and is tender. No swelling noted.

Complications: No complications

Instructions and patient follow up: Patient was instructed to leave the dressing in place for at least 24
hours. He was also instructed to clean the would with mild soap and water, and apply an antibiotic
ointment (Bacitracin) two times a day after a shower. The patient is to return to the clinic for suture
removal in 10 days. In the event of an infection, the patient was instruction to go to the emergency
room immediately.

Disposition: Patient discharged to home in stable condition.

Time completed 15:00

CPT Procedural Code 12001 Laceration repair

Signature: Megan Smith PA-C 10/09/20 Time: 16:00