SUN1633
Networker
Hello,
Wondering about this closure documentation. This scenario is for MOHS, for BCC on the right helix, with closure same day, this is all on one note.
At first, all it said was "Closure, Interpolation repair." Then it was corrected to say the following:
"Because of the size, location, and lack of recruitable tissue for repair of the created defect, a
Interpolation flap was determined necessary to maximize wound healing, relieve tension, approximate wound edges without wound edge necrosis, and minimize risk of depressed scars, railroad tracks or dehiscence.
Using a #15 blade an incision was made around the donor flap area and continued in a superficial subcutaneous plane under the flap but maintaining it's broad vascular base. Minimal if any undermining was preformed around the skin margins of the defect. Bleeding was controlled with electrocautery. The flap was advanced into position and pivotal anchor points were positioned. The distal pedical of the interpolation flap was sutured into receiving defect using 6.0 nylon sutures. The unsutured pedical portion of the interpolation flap and recipient site were occluded with xeroform gauze. The final dimension was 2.1 x 1.4 cm. Estimated blood loss: <5 cc The wound was dressed with Bacitracin ointment, Telfa, gauze, and tape. The patient was instructed on wound care and given written postoperative instructions. The patient was instructed to return to the clinic for weekly wound checks and suture removal in 30 days."
Is this enough documentation for that type closure? If not, what else is necessary? (I am thinking at least locations should be listed..)?
Thank you in advance for your response.
Wondering about this closure documentation. This scenario is for MOHS, for BCC on the right helix, with closure same day, this is all on one note.
At first, all it said was "Closure, Interpolation repair." Then it was corrected to say the following:
"Because of the size, location, and lack of recruitable tissue for repair of the created defect, a
Interpolation flap was determined necessary to maximize wound healing, relieve tension, approximate wound edges without wound edge necrosis, and minimize risk of depressed scars, railroad tracks or dehiscence. Using a #15 blade an incision was made around the donor flap area and continued in a superficial subcutaneous plane under the flap but maintaining it's broad vascular base. Minimal if any undermining was preformed around the skin margins of the defect. Bleeding was controlled with electrocautery. The flap was advanced into position and pivotal anchor points were positioned. The distal pedical of the interpolation flap was sutured into receiving defect using 6.0 nylon sutures. The unsutured pedical portion of the interpolation flap and recipient site were occluded with xeroform gauze. The final dimension was 2.1 x 1.4 cm. Estimated blood loss: <5 cc The wound was dressed with Bacitracin ointment, Telfa, gauze, and tape. The patient was instructed on wound care and given written postoperative instructions. The patient was instructed to return to the clinic for weekly wound checks and suture removal in 30 days."
Is this enough documentation for that type closure? If not, what else is necessary? (I am thinking at least locations should be listed..)?
Thank you in advance for your response.