MelodyCPC
Contributor
Please share opinions about what type of repair these two documentations support. My thoughts are that both repairs are simple because they were not multilayer closures nor did either of them have extensive cleansing of any particulate matter or foreign body. However, the provider documented Complex repair and the wounds are deep. There are no procedure details anywhere else in the documentation - just in these procedure templates.
CASE 1. fingertip injury:
Anesthesia:
Anesthesia method: Nerve block
Block needle gauge: 27 G
Block anesthetic: Lidocaine 2% w/o epi
Block injection procedure: Anatomic landmarks identified, introduced needle, incremental injection, negative aspiration for blood and anatomic landmarks palpated
Block outcome: Anesthesia achieved
Laceration details:
Location: Finger
Finger location: L index finger
Length (cm): 5
Depth (mm): 5
Pre-procedure details:
Preparation: Patient was prepped and draped in usual sterile fashion and imaging obtained to evaluate for foreign bodies
Exploration:
Limited defect created (wound extended): yes
Hemostasis achieved with: Tourniquet and direct pressure
Imaging obtained: x-ray
Imaging outcome: foreign body not noted
Wound exploration: wound explored through full range of motion
Wound extent: areolar tissue violated and underlying fracture
Wound extent: no foreign bodies/material noted and no vascular damage noted
Contaminated: yes
Treatment:
Area cleansed with: Shur-Clens and saline
Amount of cleaning: Standard
Irrigation solution: Sterile saline
Skin repair:
Repair method: Sutures
Suture size: 5-0
Suture material: Nylon
Suture technique: Simple interrupted
Number of sutures: 12
Approximation:
Approximation: Close
Repair type:
Repair type: Complex
Post-procedure details:
Dressing: Sterile dressing and splint for protection
Procedure completion: Tolerated well, no immediate complications
CONSULTS
I discussed this case with hand surgery who reviewed photo as well as x-ray. Recommends closing wound with sutures, IV antibiotics. Patient will have surgical pinning planned for tomorrow at 12:15 PM. Recommendations are for n.p.o. at midnight. Patient is agreeable to these recommendations.
CASE #2: Finger laceration
Ext: 6.1 cm linear laceration along the palmar aspect of digit #3 of left hand with normal flexion and extension. The laceration is at least 5 mm deep compromising adipose tissue. I can see down to the level of tendon but laceration does not appear to have involved/compromised any tendon or bone structure on exam. Equal radial pulses bilaterally.
Anesthesia:
Anesthesia method: Nerve block
Block needle gauge: 27 G
Block anesthetic: Lidocaine 2% w/o epi
Block injection procedure: Anatomic landmarks identified, introduced needle and anatomic landmarks palpated
Block outcome: Anesthesia achieved
Laceration details:
Location: Finger
Finger location: L long finger
Length (cm): 6.1
Depth (mm): 5
Pre-procedure details:
Preparation: Patient was prepped and draped in usual sterile fashion and imaging obtained to evaluate for foreign bodies
Exploration:
Hemostasis achieved with: Direct pressure and tourniquet
Imaging obtained: x-ray
Imaging outcome: foreign body not noted
Wound extent: areolar tissue violated and muscle damage
Wound extent: no fascia violation noted, no foreign bodies/material noted, no nerve damage noted, no tendon damage noted, no underlying fracture noted and no vascular damage noted
Contaminated: no
Treatment:
Area cleansed with: Shur-Clens and saline
Amount of cleaning: Extensive
Irrigation solution: Sterile saline
Irrigation method: Pressure wash
Skin repair:
Repair method: Sutures
Suture size: 5-0
Suture material: Nylon
Suture technique: Simple interrupted
Number of sutures: 16
Approximation:
Approximation: Close
Repair type:
Repair type: Complex
Post-procedure details:
Dressing: Antibiotic ointment, sterile dressing and splint for protection
Procedure completion: Tolerated well, no immediate complications
The patient's laceration was repaired by myself. He was fitted for a dressing and a finger splint by RN in advance of discharge. He was treated with cefadroxil with concern for the deep penetration of the laceration down nearly to the level of compromising the tendon. He appeared to have normal range of motion on exam with normal sensation. He tolerated laceration repair very well. He should return for suture removal in 10 to 12 days. He should follow-up with hand surgery. I will start him on an antibiotic course to be taken twice daily over the course of the next week. Hydrocodone was given for pain in advance of discharge and further prescribed for pain control at home. Keep the wound clean and dry.
CASE 1. fingertip injury:
Anesthesia:
Anesthesia method: Nerve block
Block needle gauge: 27 G
Block anesthetic: Lidocaine 2% w/o epi
Block injection procedure: Anatomic landmarks identified, introduced needle, incremental injection, negative aspiration for blood and anatomic landmarks palpated
Block outcome: Anesthesia achieved
Laceration details:
Location: Finger
Finger location: L index finger
Length (cm): 5
Depth (mm): 5
Pre-procedure details:
Preparation: Patient was prepped and draped in usual sterile fashion and imaging obtained to evaluate for foreign bodies
Exploration:
Limited defect created (wound extended): yes
Hemostasis achieved with: Tourniquet and direct pressure
Imaging obtained: x-ray
Imaging outcome: foreign body not noted
Wound exploration: wound explored through full range of motion
Wound extent: areolar tissue violated and underlying fracture
Wound extent: no foreign bodies/material noted and no vascular damage noted
Contaminated: yes
Treatment:
Area cleansed with: Shur-Clens and saline
Amount of cleaning: Standard
Irrigation solution: Sterile saline
Skin repair:
Repair method: Sutures
Suture size: 5-0
Suture material: Nylon
Suture technique: Simple interrupted
Number of sutures: 12
Approximation:
Approximation: Close
Repair type:
Repair type: Complex
Post-procedure details:
Dressing: Sterile dressing and splint for protection
Procedure completion: Tolerated well, no immediate complications
CONSULTS
I discussed this case with hand surgery who reviewed photo as well as x-ray. Recommends closing wound with sutures, IV antibiotics. Patient will have surgical pinning planned for tomorrow at 12:15 PM. Recommendations are for n.p.o. at midnight. Patient is agreeable to these recommendations.
CASE #2: Finger laceration
Ext: 6.1 cm linear laceration along the palmar aspect of digit #3 of left hand with normal flexion and extension. The laceration is at least 5 mm deep compromising adipose tissue. I can see down to the level of tendon but laceration does not appear to have involved/compromised any tendon or bone structure on exam. Equal radial pulses bilaterally.
Anesthesia:
Anesthesia method: Nerve block
Block needle gauge: 27 G
Block anesthetic: Lidocaine 2% w/o epi
Block injection procedure: Anatomic landmarks identified, introduced needle and anatomic landmarks palpated
Block outcome: Anesthesia achieved
Laceration details:
Location: Finger
Finger location: L long finger
Length (cm): 6.1
Depth (mm): 5
Pre-procedure details:
Preparation: Patient was prepped and draped in usual sterile fashion and imaging obtained to evaluate for foreign bodies
Exploration:
Hemostasis achieved with: Direct pressure and tourniquet
Imaging obtained: x-ray
Imaging outcome: foreign body not noted
Wound extent: areolar tissue violated and muscle damage
Wound extent: no fascia violation noted, no foreign bodies/material noted, no nerve damage noted, no tendon damage noted, no underlying fracture noted and no vascular damage noted
Contaminated: no
Treatment:
Area cleansed with: Shur-Clens and saline
Amount of cleaning: Extensive
Irrigation solution: Sterile saline
Irrigation method: Pressure wash
Skin repair:
Repair method: Sutures
Suture size: 5-0
Suture material: Nylon
Suture technique: Simple interrupted
Number of sutures: 16
Approximation:
Approximation: Close
Repair type:
Repair type: Complex
Post-procedure details:
Dressing: Antibiotic ointment, sterile dressing and splint for protection
Procedure completion: Tolerated well, no immediate complications
The patient's laceration was repaired by myself. He was fitted for a dressing and a finger splint by RN in advance of discharge. He was treated with cefadroxil with concern for the deep penetration of the laceration down nearly to the level of compromising the tendon. He appeared to have normal range of motion on exam with normal sensation. He tolerated laceration repair very well. He should return for suture removal in 10 to 12 days. He should follow-up with hand surgery. I will start him on an antibiotic course to be taken twice daily over the course of the next week. Hydrocodone was given for pain in advance of discharge and further prescribed for pain control at home. Keep the wound clean and dry.