Document Laceration Repair Procedures

You can document the laceration repair procedures that are performed in the office.

1. On the Home template, click the Forms link, select Lacerations on the Navigation window, and click OK.
   The Laceration Repair - Procedure template opens.

   

2. Select Obtain patient consent, if consent was obtained prior to the procedure.
3. In the Procedure section, select Laceration prepped and draped using sterile technique, if applicable.
4. To document the physical exams for skin and hair, click the PE Skin link.
5. Select the length of the laceration for the Simple or Intermediate classification.
   The Indication, Code, and Status fields are displayed in the Procedure section, and the diagnosis search window opens.

   

6. In the diagnosis search window, do the following:
   1. Type the keyword in the search field, and click Search.
      The list is filtered to show only the items that contain the keyword.
   2. Select the diagnosis from the list.
   3. Click Select.
      The diagnosis search window closes, and the Laceration Repair - Procedure template displays the Indication and Code fields automatically filled with the clinical description and ICD Code.
7. Click the Status field, select the status from the Get Diagnosis Status window, and then click OK.
8. Select the anesthetic used, and then click the corresponding field to select the dosage from the list.
9. Select the appropriate options for the suture.
   The Wound check and Suture removal fields are automatically filled with the time intervals. You can click the field and update the values.
10. In the Dressing, wound care & follow section, select Applied sterile dressing and discussed wound care instructions, if applicable.
11. To indicate that the time interval for the wound check is based on the situation, select PRN.
12. Enter any additional details in the Comments field.
13. Click Save & Close.