Here's another, a bit more "complex" - this is for a laceration of the extremity. The exam and the repair are included. I simply would dictate the size of the lac, area, as well as the percent xylocaine and whether it is with or without Epi.
Here is the starter macro that comes up with saying "exam laceration extremity":
General: WNWD in NAD
Skin: cm. laceration of the aspect of the
Neuro: Circulation and sensation intact distally. Motor function 5/5.
The area was anesthetized locally with % xylocaine epinephrine., and prepped with Betadine solution, allowing time for it to dry on the skin. The area was prepped and draped in the usual sterile manner. After careful exploration of the wound to ensure that there was no foreign body or tendon involvement, the laceration was closed with sutures of Ethilon in simple interrupted fashion, with apposition and hemostasis. A non-stick dressing was applied.
Here is an example of a filled-in macro - it only required me to insert dictation at seven spots in the narrative:
General: WNWD in NAD
Skin: 1.5 cm. laceration of the volar aspect of the proximal phalanx of the right ring finger.
Neuro: Circulation and sensation intact distally. Motor function 5/5.
The area was anesthetized locally with 1% xylocaine without epinephrine., and prepped with Betadine solution, allowing time for it to dry on the skin. The area was prepped and draped in the usual sterile manner. After careful exploration of the wound to ensure that there was no foreign body or tendon involvement, the laceration was closed with 4 sutures of 4-0 Ethilon in simple interrupted fashion, with apposition and hemostasis. A non-stick dressing was applied.
And here is what I get with "plan laceration extremity" (there is one spot I add dictation, that is for the time to suture removal):
Instructions printed and provided to patient:
You should limit use of the injured area, and may elevate it to relieve pain. You may use OTC medications such as Tylenol for pain, as the manufacturer directs.
Cleanse the area daily with soap and water or hydrogen peroxide, dry thoroughly, and follow this with triple antibiotic ointment and a non-stick dressing. Except for bathing, you should keep the wound dry, unless otherwise stated.
Call if any tenderness, pus, or erythema of surrounding tissue appears.
Return for a wound recheck in 2 days, and for suture removal in days.
