Procedure Note:Procedure Name: Incision and Drainage of AbscessIndication: Pain, risk of further infectionLocation:.Pre-Procedure Diagnosis: AbscessPost-Procedure Diagnosis: Abscess, drainedInformed consent was obtained before procedure started.Description:Area prepped and draped in usual sterile fashion. Local anesthesia achieved using Lidocaine 1%.without epinephrine,.cc. 11 blade, a.cm incision was made and.cc of purulent material drained from wound. Wound was copiously irrigated and.packing placed. A sterile bandage was applied. Patient tolerated procedure well. Return to care.
Tray List:. Chux (2). Betadine/Povidone Iodine (1 bottle or 3 swab-sticks).
Lidocaine 1% without epinephrine (1 bottle). Alcohol prep pads. Syringe, 5cc (1). Syringe, 20cc (1). Needle, 18 gauge, 1-0.5 inch length (1). Needle, 27 gauge, 1.25 inch length (1).
Needle, 30 gauge, 0.5 inch length (1). No. 11 Blade (1). Swab, for microbiology/culture (1). Swab, sterile (2). Gauze, 4x4, sterile (5). Gauze, 2x2, sterile (5).
Gauze, 4x4, non-sterile (1 pack). Gauze, 2x2, non-sterile (1 pack). Normal Saline or Sterile Water (1 Liter).
Medical Procedure Note Template
Cup, sterile urine sample (1). Gauze, ribbon/packing, 1/4 inch width (1 bottle).
Tape, paper, 1 inch width. Re-Pack wound. Procedure Note:Procedure Name: Laceration RepairIndication: Reduce risk of infectionLocation:.Pre-Procedure Diagnosis: LacerationPost-Procedure Diagnosis: Laceration, repairedInformed consent was obtained before procedure started.Description:Area prepped and draped in usual sterile fashion. Local anesthesia achieved using Lidocaine 1%.without epinephrine,.cc. Wound was copiously irrigated.
5-0 Nylon interrupted sutures were placed. A sterile bandage was applied. Patient tolerated procedure well. Return to care. for suture removal.
Procedure Note:Procedure Name: ExcisionIndication: Pain, risk of infectionLocation:.Pre-Procedure Diagnosis:.Post-Procedure Diagnosis:., removedInformed consent was obtained before procedure started.Description:Area prepped and draped in usual sterile fashion. Local anesthesia achieved using Lidocaine 1%.without epinephrine,.cc. 15 blade, a.cm incision was made. Wound was copiously irrigated.
5-0 Nylon interrupted sutures were placed. A sterile bandage was applied. Patient tolerated procedure well.
Return to care. Tray List:. Chux (2). Betadine/Povidone Iodine (1 bottle or 3 swab-sticks). Lidocaine 1% without epinephrine (1 bottle). Alcohol prep pads. Syringe, 5cc (1).
Syringe, 20cc (1). Needle, 18 gauge, 1-0.5 inch length (1). Needle, 27 gauge, 1.25 inch length (1). Needle, 30 gauge, 0.5 inch length (1).
No. 15 Blade (1). Swab, sterile (2). Gauze, 4x4, sterile (5). Gauze, 2x2, sterile (5). Normal Saline or Sterile Water (1 Liter).
Cup, sterile urine sample (1). Needle driver/holder (1). Pickups with teeth (1). Hemostat, small (1).
Scissors for suturing, small sterile (1). Suture, nylon 5-0 (2 packs). Tape, paper, 1 inch width.
Joint Injection. Procedure Note:Procedure Name: Joint InjectionIndication: PainLocation:.Pre-Procedure Diagnosis:.ArthritisPost-Procedure Diagnosis: SameInformed consent was obtained before procedure started.Description:Area prepped in usual sterile fashion. Local anesthesia achieved using Gebauer's cold spray. Lidocaine 1% without epinephrine 2cc and Kenalog 40mg in 1mL was injected into joint using. approach.
A sterile bandage was applied. Patient tolerated procedure well. Return to care. Procedure Note:Procedure Name: Toenail RemovalIndication: Pain, infectionLocation:.great toePre-Procedure Diagnosis: Ingrown ToenailPost-Procedure Diagnosis: Same, removedInformed consent was obtained before procedure started.Description:Area prepped and draped in usual sterile fashion.
Local anesthesia achieved using Lidocaine 1%.without epinephrine,.cc in a digital block. Using the.toenail clippers, the toenail was cut to its emergence from the matrix. Then using the.spatula the toenail was undermined to the.margin. Then using the.toenail grabber the toenail was removed. Wound was copiously irrigated and.packing placed. A sterile bandage was applied.
Patient tolerated procedure well. Return to care.