AI Scribe for Urgent Care

URGENT CARE — LACERATION REPAIR
Date: 04/22/2026 17:42 | Provider: PatientNotes Clinical Team
CPT: 99214-25 (E&M, moderate MDM) + 12002 (simple closure, scalp/neck/extremity 2.6-7.5 cm)

CHIEF COMPLAINT:
"Cut my hand on a kitchen knife about 90 minutes ago."

HPI:
34-year-old right-hand-dominant male presents with a laceration to
the dorsum of the left hand. Was slicing onions and the knife slipped.
Bleeding controlled with direct pressure at home. Denies LOC, no
other injuries, no foreign body sensation. Last tetanus booster:
patient unsure, "more than 10 years ago." No prior tendon or nerve
injury to the hand.

PMH: None.
Allergies: NKDA.
Medications: None.
Tetanus: Likely overdue (>10 years).

REVIEW OF SYSTEMS:
Negative except as in HPI. No fever, no numbness, no weakness in
the affected hand.

OBJECTIVE:
Vitals: BP 128/76, HR 78, RR 14, Temp 36.7°C, SpO2 99% RA, Pain 4/10.
General: Alert, comfortable, in no distress.

Focused exam — left hand, dorsum:
- 4 cm linear laceration overlying the 2nd-3rd metacarpal junction,
  oblique orientation. Edges clean, mildly contaminated with onion
  debris. No active arterial bleeding.
- Depth: through dermis, superficial subcutaneous fat visible.
  No fascia, tendon, or bone exposed. No foreign body palpable.
- Neurovascular: 2-point discrimination intact at all five fingertips
  (<5 mm). Capillary refill <2 sec. Radial and ulnar pulses 2+.
  No paresthesia.
- Tendon function: full active and resisted extension and flexion
  at MCP, PIP, and DIP joints of all digits. No extensor lag.
- ROM at wrist and digits: full and painless against gravity.

PROCEDURE — Laceration Repair:
- Consent: Verbal informed consent obtained, including risks of
  bleeding, infection, scarring, retained foreign body, and need
  for revision.
- Cleansing: Wound irrigated with 250 mL normal saline under
  pressure (18-gauge angiocath on 60 mL syringe). Onion debris
  removed. Wound re-inspected — no remaining foreign body.
- Anesthesia: 1% lidocaine with epinephrine, 4 mL infiltrated
  around wound margins (max dose for 70 kg patient: 7 mg/kg with
  epi = 490 mg or 49 mL of 1% — well within limit). Anesthesia
  achieved after 4 minutes, confirmed by absence of pinprick
  sensation.
- Closure: Simple interrupted sutures, 4-0 nylon (Ethilon),
  6 sutures total to approximate wound edges. Even tension, no
  inversion. Wound edges well-approximated, hemostasis achieved.
- Dressing: Bacitracin ointment, non-adherent gauze, gauze wrap,
  and self-adherent wrap (Coban). Patient instructed to keep dry
  for 48 hours.
- Tetanus: Tdap administered today (Boostrix lot #FD2026-04, 0.5 mL
  IM left deltoid). Patient counseled on injection-site soreness.
- Estimated blood loss: <10 mL.

ASSESSMENT:
1. Open wound, dorsum of left hand, 4 cm, simple repair, no neuro-
   vascular or tendon involvement. (S61.401A)
2. Tetanus prophylaxis administered, prior status uncertain. (Z23)

PLAN:
1. Suture removal in 10-12 days. Patient may follow up with PCP
   or return to urgent care.
2. Keep dressing dry x 48 hours, then may shower with bandage
   covered. Daily dressing change after that with bacitracin and
   clean gauze.
3. Return precautions reviewed: increasing pain, redness extending
   beyond wound margins, purulent drainage, fever, red streaking,
   numbness or weakness, or signs of tendon dysfunction — return
   to urgent care or ED.
4. Acetaminophen 650 mg PO q6h PRN pain, alternating with ibuprofen
   400 mg PO q6h PRN if no contraindication. No prescription opioid
   indicated.
5. No antibiotic prophylaxis indicated (clean wound, irrigated,
   <6 hours, no immunocompromise) — discussed with patient.
6. Work note provided: light duty x 5 days, no heavy lifting >10 lb
   or repetitive grip with the left hand.

Suggested ICD-10: S61.401A (open wound L hand, initial encounter),
                  Z23 (encounter for immunization).
Suggested CPT: 99214-25 (E&M, moderate MDM with procedure on same
               day, modifier 25),
               12002 (simple repair, 2.6-7.5 cm, extremity),
               90715 (Tdap administration).