Clinical note · #64
Procedures & modifiers
Patient: Jane Smith · Date of service: 09/11/2024
Chief complaint
Laceration on the right hand.
History of present illness
The patient presents with a 4 cm laceration on the right hand sustained during cooking. No signs of infection or foreign bodies.
Physical exam
The laceration is on the dorsal aspect of the right hand, measuring 4 cm, with mild bleeding and clean edges. The surrounding skin shows no signs of infection.
Procedure
The area was cleaned and anesthetized with 1% lidocaine. The laceration was closed in a single layer using 5-0 nylon sutures. The wound was dressed, and the patient was advised on post-procedure care.
Assessment / plan
- Laceration repair.