I will give what I can, but no easy way to copy and paste note, then scrub.
Now this is a worker's compensation claim, so wording can be a little different.
Injury Description: Patient received a burn on left leg after molten steel spilled onto his left lower leg and foot, burning through his boots.
HPI: Primary problem is a third degree burn located on the lateral side of leg and foot and describes it as burning. He considers it sever with less then a day since the onset of the burns. The pain seems to be constant with a pain level of 9/10.
Examination:
Left lower leg: A burn in present over the lower leg. The central area is white. The patient does not have sensation in the center of the burn area. The area is about 2 cm in diameter. The skin edges are burnt and crisp. Erythema is present over lower leg.
Left ankle: A burn in present over the lower leg. The central area is white. The patient does not have sensation in the center of the burn area. The area is about 4 cm in diameter. The skin edges are burnt and crisp. Erythema is present over ankle.
Procedures: Wound on the leg and ankler were cleaned. Burns of the leg was debrided through the dermis, removing the burnt and crisp edges. A good margin was achieved. Wounds were dressed with silvadene. Burns of the ankle were debrided, removing the burnt and crisp edges. A good margin was achieved. Wounds were dressed with silvadene.
Side note:
Patient was referred to a burn center after the visit, but because of WC, the patient was scheduled 2 days after the accident. So it will not interfere with coding this.