Debridement procedure note

Page 1 of 1

DEBRIDEMENT PROCEDURE NOTE

Date: ____/____/_____ ______ Surgeon ____________________ Assistant _____________________

mth day yr time
Pre-procedure diagnosis _______________________________________________________________________

Post procedure diagnosis _______________________________________________________________________
OR procedure: This form may supplement the dictated operative report and serve as the postoperative procedure note.

Bedside procedure: This form may serve as your procedure report when done at the bedside.
 Informed procedure consent complete, signed, and present in chart

 Patient identified per hospital policy

Procedure Description:

 Excisional debridement (surgical removal/cutting away of tissues)

 Non-excisional debridement (non-operative brushing/irrigating/scrubbing/washing of tissue)
Anesthesia:  General  Spinal  Epidural  MAC  Sedation  Local  Other ____________________
Technique (check one):

 Excisional (surgical removal/cutting away/resection)  Non-Excisional (trimming/scrubbing/brushing/washing/irrigation)
Instrument(s) used (check all that apply):

 Scalpel  Laser  Scissors  Ronguer  Currette  Brush  Pulsatile jet lavage

 Other ____________________
Nature of tissue debrided (check all that apply):

 Non-viable (necrotic/devitalized/gangrenous/ischemic)  Grossly infected  Hyperkeratotic  Fibrotic  Calloused

 Slough  Loose fragments  Other ______________________________________
Appearance and size of wound(s) after debridement (check all that apply):

 Viable (pink bleeding tissue)  Non-viable tissue  Other __________________________________________________

Size of wound after debridement (dimensions in cm) __________­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­___________
Depth of debridement – Debridement into and including (check all that apply):

 Skin  Subcutaneous tissue  Fascia  Muscle  Tendon  Ligament  Bone

Specimens removed and disposition  None________________________________________________________________
Estimated blood loss if more than minimal: _________________
Patient condition at conclusion of procedure:  Stable  Other _____________________________________________
Comments _______________________________________________________________________________________________
________________________________________________________________________________________________________

____________________________________ _____/_____/_____ _________

Provider signature/Title mth day yr time

25200795 (4/11) Digital Ink Form #2701.50000.17.01