Patient presents with a lip laceration.  Chief complaint is lip injury, trauma to the lip, or cut lip.  History of present illness includes the mechanism of injury, such as a fall, blunt trauma, or penetrating injury.  Location of the laceration is documented, specifying upper lip laceration, lower lip laceration, or involvement of the vermilion border.  The size and depth of the wound are noted in millimeters or centimeters.  Assessment includes evaluation for associated injuries, such as dental injury, oral lacerations, or facial fractures.  Wound characteristics, including presence of active bleeding, contamination, or foreign bodies are described.  Neurovascular status of the lip is assessed.  Differential diagnosis may include abrasion, contusion, or puncture wound.  Treatment plan includes wound cleansing with normal saline, exploration for foreign bodies, and assessment of the need for lip repair, sutures, or adhesives.  Anesthesia considerations are documented, such as topical anesthetic or local infiltration.  Post-procedure instructions are provided, including wound care, pain management with over-the-counter analgesics, and signs of infection to watch for.  Follow-up care is scheduled as needed.  ICD-10 codes for lip laceration are documented appropriately, such as S01.51XA for laceration of upper lip, vermilion border, S01.52XA for laceration of lower lip, vermilion border, or S01.50XA for laceration of lip, unspecified.  CPT codes for repair, such as 40800 for simple repair of lip, are documented if performed.