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“You can get past the dead end. You can break through the ceiling. I did and so have countless others.”

Clinical Pearl Wednesday #56

Anytime you ever repair a soft tissue injury such as sutures for a laceration, you need to ensure you document the patient’s functionality after the procedure.

In your procedure documentation, simply document “Patient neurovascularly and functionally intact after the repair. Patient tolerated well.”

This will protect you if something were to happen down the road. For example, lets say that you repaired a laceration to the base of the thumb and the patient ended up losing function to that thumb a month later. As long as you documented that there was no tendon or nerve involvement, the patient was neurovascularly and functionally intact before and after the procedure, then you should be adequately protected. The issue could have been non-compliance on the patients part.

A quick 10 second exam and a sentence in your note could really save you some serious headaches in the future.

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