Incision and Drainage Procedure Note

Performed by: @ME@, MD

Indication: {INDICATION:20615}

Consent: {CONSENT:20165}

Time out performed: Immediately prior to the procedure a “time out” was called to verify the correct patient, the correct procedure, equipment, support staff and site/side marked as required.  

Procedure: The patient was positioned appropriately and the skin over the incision site was {PREP FOR PROCEDURE:20153}. Local anesthesia was {ANESTHESIA:20401}.  An incision was then made over the {INCISION SITE:20616} and through the {Blank single:19197::”Skin”, “Subcutaneous tissue”, “muscle layer”,”***”} but did not enter the {Blank single:19197::”Skin”, “Subcutaneous tissue”, “muscle layer”,”***”}.  {DRAINAGE AMT:20617} material was expressed. Loculations were {LOCULATIONS:20618}. The drainage cavity was then {CAVITY DISP:20619}. The patient’s tetanus status {TETANUS STATUS:20252}.

The patient tolerated the procedure {TOLERATED:20124}.

Complications: {COMPLICATIONS:20589}