Needle Stick Injury

Patient presents with a needlestick injury sustained on [date] at approximately [time].  The injury occurred in the [location, e.g., right hand, left index finger] while the patient was [activity resulting in injury, e.g., administering a subcutaneous injection, recapping a needle, disposing of sharps].  The source patient, if applicable, is [source patient name or identifier] and their known bloodborne pathogen status is [status, e.g., positive for Hepatitis C, unknown].  The exposed employee's bloodborne pathogen status is [employee status, e.g., Hepatitis B immune].  The wound was immediately washed with soap and water.  The injury site exhibits [description of wound, e.g., pinpoint puncture wound, bleeding, erythema, edema].  Patient reports [symptoms, e.g., pain at the injection site, no other complaints, anxiety regarding potential exposure].  Post-exposure prophylaxis (PEP) was discussed, including risks and benefits.  [Document patient's decision regarding PEP, e.g., Patient elected to initiate PEP, Patient declined PEP at this time].  Baseline labs ordered include [list labs, e.g., HIV antibody test, Hepatitis B surface antigen, Hepatitis C antibody test].  Incident reported to occupational health per facility protocol.  Patient education provided on signs and symptoms of bloodborne infections, follow-up testing, and prevention of future needlestick injuries.  Patient instructed to return for follow-up evaluation on [date].  ICD-10 code:  [appropriate ICD-10 code, e.g., X06.0, T23.1XXA].