Burn Wound Debridement
[Partial-thickness / full-thickness] burns, [X]% TBSA, [location]
Same
Burn wound debridement and dressing, [X]% TBSA, [location], day [X] post-injury
[***, MD/DO]
[Resident / Nurse name]
[General endotracheal / IV sedation and analgesia]
Patient presents on [day X] post-[flame / scald / chemical / electrical] burn with [X]% TBSA [partial-thickness / full-thickness] burns involving [location]. [Wound requires debridement of devitalized tissue and dressing change under anesthesia given pain/extent.] [Wounds not yet ready for excision and grafting; dressing planned.] Consent [obtained / waived].
[Partial-thickness / full-thickness] burn wounds [X]% TBSA. [Blistered / de-epithelialized / eschar formation] noted at [location]. [Wound culture sent, results pending.] [Wound bed [healthy / infected / colonized].]
The patient was brought to the operating room [/ procedure room] and placed under [general / IV sedation]. The burn wounds were exposed and assessed.
Burn wounds debrided by removal of [loose / devitalized] tissue, blisters, and necrotic debris using [gauze / forceps and scissors / hydrosurgery unit (Versajet) at [X] setting]. [Superficial eschar removed with [gentle scrubbing / blade], viable dermis underlying.] Wound beds irrigated with normal saline.
Wounds covered with [Mepitel Ag / Mepilex Ag / Aquacel Ag / Xeroform / silver sulfadiazine cream (legacy; requires daily changes, impairs re-epithelialization)] followed by [ABD pads / elastic gauze wrap]. [Facial burns treated with [bacitracin / petrolatum gauze] and left open.]
Patient tolerated the procedure well.
None
[Wound culture swab sent / None]
Minimal
None
Patient returned to burn ICU / burn unit. Next wound assessment in [2-3] days.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Partial-thickness / full-thickness] burns, ***% TBSA, [location], day *** post-injury
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Burn wound debridement and dressing, ***% TBSA, [location]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [General endotracheal / IV sedation]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX on day *** post-[flame / scald / chemical] burn with ***% TBSA [partial- / full-thickness] wounds. Debridement and dressing change under anesthesia indicated. Consent [obtained / waived].
FINDINGS: [Partial-thickness / full-thickness] wounds ***% TBSA. [Blistered / eschar / de-epithelialized] at [location]. Wound bed [healthy / infected]. [Culture sent.]
DESCRIPTION OF PROCEDURE:
Patient to [OR / procedure room]; [general / IV sedation]. Wounds exposed and assessed. Debridement of devitalized tissue, blisters, and necrotic debris with [gauze / Versajet at *** setting]. Wound beds irrigated with normal saline. Wounds dressed with [Mepitel Ag / Aquacel Ag / Xeroform] and ABD pads. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: [Wound culture sent / None]
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient to burn [ICU / unit]. Reassessment in 2-3 days.
Signed: .ME, .MYDEGREE
.TODAYVariants
Hydrosurgical debridement (Versajet)
Precise, low-trauma debridement using high-velocity waterjet. Useful for hands, face, and irregular surfaces. Document power setting and area treated. Same reporting options apply.
Chemical/electrical burn
Chemical burns require copious irrigation before debridement. Electrical burns may have deceptively small surface area with deep tissue injury. Document wound appearance vs. mechanism mismatch.
Charting Tips
- Document TBSA debrided in the note (determines reporting selection)
- Note wound depth assessment at each session (superficial vs. deep partial vs. full thickness)
- Document dressing selection and rationale (antimicrobial, non-adherent, absorptive)
- Send wound cultures when infection suspected; document site and result
- Note day post-injury, as changes in wound depth at serial assessments guide excision timing
Documentation & Reimbursement Considerations
- Primary service: Report Burn Wound Debridement as the primary service when it is the definitive operation performed.
- Document TBSA carefully, as it determines reporting selection.
- These reporting options apply to debridement and dressing change under anesthesia. Bedside dressing changes at a lower level of care (no anesthesia) are typically billed as wound management E/M. When anesthesia is used, bill the procedure code; anesthesia is billed separately by anesthesia.
- Initial burn wound evaluation and first dressing are included in the E/M for the admission day. Document each session separately with date, TBSA debrided, and dressing applied.
- 0-day global period: each debridement session is separately billable. Routine daily dressing changes by nursing staff are not surgeon procedure fees; they are facility charges. The surgeon's procedure fee applies when the surgeon personally performs or directly supervises the wound care session.
- Prior authorization is typically required. Document agent, concentration, application time, and area treated.