Laceration repair note
United States | Urgent care

Blank documentation outlines for US practice. Adapt to the encounter and your practice requirements; complete only findings and care actually documented.

ENCOUNTER
Patient name: [ ]
Date of birth: [ ]
Date and time of encounter: [ ]
Clinician: [ ]

WOUND EVALUATION
Time and mechanism of injury: [ ]
Site, laterality, length and depth: [ ]
Contamination, foreign body and associated injury assessment: [ ]
Functional and neurovascular findings: [ ]
Tetanus history assessed and action taken: [ ]
Relevant history, medications and allergies: [ ]

CONSENT AND PROCEDURE
Options, risks and alternatives discussed; consent obtained or declined: [ ]
Site verification: [ ]
Anesthetic agent, concentration, amount and route if used: [ ]
Cleansing, irrigation and exploration performed: [ ]
Closure method, material and number of sutures or staples if used: [ ]
Dressing, complications and patient response: [ ]

DISPOSITION
Post-procedure reassessment: [ ]
Wound care and return precautions discussed: [ ]
Follow-up and removal plan if applicable: [ ]