|
HPI
|
|
|
Sutures or staples?
|
How many sutures/staples were placed?
|
|
How many days ago were sutures placed?
|
|
|
Location:
• • •
|
Well appearing in clinic
|
|
No fevers
|
Tetanus
|
|
Additional notes
|
|
|
Associated symptoms
• • •
|
|
|
ROS
|
|
|
Skin (positive)
• • •
|
Skin (negative)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Insert Macro Here
|
All systems otherwise negative.
|
|
|
|
|
PE
|
|
|
Location:
• • •
|
|
|
# of sutures/staples removed
|
|
|
Skin macros (positive)
• • •
|
Skin (negative)
• • •
|
|
Additional Skin Findings
|
|
|
NVI
|
|
|
PE: Superficial Exam
|
Head to toe exam (excluding abdominal exam)
|
|
PE Macro:
|
|
|
PHOTO
|
PHOTO
|
|
MDM
|
|
|
MEDICAL DECISION MAKING
|
|
|
Diagnosis: Laceration - Suture Removal
|
Diagnosis:
|
|
|
|
|
DISCHARGE
|
|
|
Plan Notes
|
|
|
Discharge pt home
|
|
|
Clinician Attestation
|
|
