Tangential Excision and Split-Thickness Skin Grafting
[Deep partial-thickness / full-thickness] burns, [X]% TBSA, [location], requiring excision and grafting
Same
Tangential excision of burn wound, [X] sq cm, and split-thickness skin autograft from [donor site], [meshed / sheet graft]
[***, MD/DO]
[Resident / Fellow name]
General endotracheal. Active warming measures. Two large-bore IVs. Blood products available.
Patient with [X]% TBSA [deep partial- / full-thickness] burns presents for operative excision and grafting of [location] wounds. Wounds [confirmed full thickness on clinical exam / non-healing partial thickness at day [X] post-injury]. [TBSA x 4 mL/kg = [X] mL; Parkland formula initiated.] Hemoglobin [X], platelets [X]. Blood products available. Risks including blood loss, graft failure, donor site morbidity, and infection discussed. Consent obtained.
[Deep partial-thickness / full-thickness] burn wounds [X] sq cm. Tangential excision to viable dermis/fat confirmed by [punctate bleeding / clinical appearance]. Donor site: [thigh / back / scalp] (adequate supply for [X] sq cm coverage). Graft take [expected excellent / borderline (wound bed clean)].
The patient was positioned [supine / prone]. Tourniquets were applied to [bilateral thighs / upper extremities] at [X] mmHg. Burn wounds were prepped with [chlorhexidine / Dakin's solution].
EXCISION: Tangential excision was performed using a [Goulian (Weck) / Watson] knife set at [0.010-0.015 inch] thickness, taking sequential layers from the burn wound until viable dermis [/ fat] was reached, confirmed by [uniform punctate bleeding / tissue appearance]. [Fascial excision performed for [X] area due to full-thickness injury to fat.] Total excised area: [X] sq cm. Hemostasis achieved with [electrocautery / topical thrombin / epinephrine-soaked lap pads / tourniquet].
DONOR SITE: A split-thickness skin graft [X/1000 inches thick] was harvested from the [right / left thigh / back] using a [Zimmer / Brown] dermatome at [X/1000] inch thickness. Donor site dressed with [Xeroform / Opsite / Telfa].
GRAFTING: Donor skin was [meshed [X]:1 / used as sheet graft]. Graft [X] sq cm applied to the excised wound bed. Secured with [staples / interrupted 4-0 chromic suture at edges]. Graft dressed with [Xeroform / Adaptic] then [ABDs / bolster dressing / VAC sponge at [X] mmHg].
[Allograft placed over areas not covered with autograft.]
Tourniquets released. Hemostasis confirmed. Patient tolerated the procedure well.
None
None
[X] mL
[None / VAC dressing at [X] mmHg]
Patient returned to burn ICU. Graft check at [3-5] days. Donor site care per protocol.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Deep partial-thickness / full-thickness] burns, ***% TBSA, [location]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Tangential excision, *** sq cm, and STSG from [right thigh / back / scalp], [meshed *** : 1 / sheet graft]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal, warming, blood products available
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with ***% TBSA [deep partial- / full-thickness] burns requiring excision and grafting. [Non-healing partial thickness at day *** post-injury / clinical full thickness.] Hgb ***, platelets ***. Risks including blood loss, graft failure, and donor site morbidity discussed. Informed consent obtained.
FINDINGS: [Deep partial-thickness / full-thickness] wound *** sq cm. Tangential excision to viable dermis/fat with punctate bleeding confirmed. Donor site [thigh / back] adequate.
DESCRIPTION OF PROCEDURE:
Patient [supine / prone]. Tourniquets at *** mmHg. Wounds prepped. Tangential excision with [Goulian / Watson] knife at 0.010-0.012 inch until punctate bleeding / viable fat. Total *** sq cm excised. [Fascial excision for *** area.] Hemostasis with electrocautery and tourniquet. Donor STSG *** / 1000 inches harvested from [right thigh / back] with [Zimmer / Brown] dermatome. Donor site dressed with Xeroform. Graft [meshed *** : 1 / sheet], *** sq cm applied to wound bed and secured with staples. Dressed with [Xeroform / Adaptic + ABD / VAC at *** mmHg]. Tourniquets released. Hemostasis confirmed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: None
COMPLICATIONS: None
DRAINS: [None / VAC dressing]
DISPOSITION: Patient to burn ICU. Graft check at 3-5 days.
Signed: .ME, .MYDEGREE
.TODAYVariants
Fascial excision
For deep full-thickness burns with necrotic fat. More hemostatic than tangential excision. Results in flat, cosmetically inferior graft bed. Document indication and extent.
Sheet graft (face/hands)
Unmeshed sheet graft preferred for face, neck, and hands. Better cosmetic and functional result. Document as unmeshed sheet graft. Bolster or tie-over dressing required to prevent shear.
Allograft (temporary coverage)
Used when donor supply is insufficient or wound bed is not ready. Documents as temporary biological dressing. Autograft at subsequent session.
Charting Tips
- Document total excision area and graft area in square centimeters (drives reporting billing)
- State tangential excision endpoint (punctate bleeding for dermis vs. viable fat for full thickness)
- Note dermatome blade thickness and donor site location and dimensions
- Document mesh ratio or sheet graft and fixation method
- Record graft dressing type and planned graft check timing
- Blood product use should be documented, as large burns commonly require intraoperative transfusion
Documentation & Reimbursement Considerations
- Report Tangential Excision and Split-Thickness Skin Grafting as the primary service when it is the definitive operation performed.
- Document graft recipient area in square centimeters.
- Donor site harvest is included in the graft codes. Do not separately bill donor site. Document donor site location, harvest thickness (in thousandths of an inch, e.g., 12/1000), and dimensions.
- Meshing the graft does not change the reporting options but should be documented. Mesh ratio (1:1, 1:1.5, 2:1) and coverage area should be recorded. Document whether an unmeshed sheet graft (better cosmesis) or meshed graft (larger coverage) was used and why.
- These are temporary biological dressings, not definitive grafting, and are separately billable. Document size applied in sq cm.
- Both are billable when both are performed. These reporting options are frequently undercoded.