Procedure Note
Required for all procedures which require consent and/or are not otherwise done routinely.
The Note must either be written or dictated as soon as the procedure is done.
The Note should include the following:
· Date:
· Time:
· Name of the procedure being done:
· Indications:
· Patient consent:
ü Document that the indications, risks and alternatives to the procedure were explained to the patient. Note that the patient was given the opportunity to ask questions and that the patient consented to the procedure in writing
· Pertinent Lab Values: i.e. coags, CBC
· Type of Anesthesia used: i.e. 2% lidocaine
· Description of the procedure: Using sterile prep, local anesthesia, standard position needed for the procedure, device and technique being used.
· Complications:
· Estimated blood loss ( if indicated)
· Disposition: Pt tolerated the procedure well.
Signature: In clear and legible hand writing.
Example:
2/7/07 15:30
Procedure:Double Lumen Dialysis Catheter
Indication: Dialysis access
Consent: Signed consent in chart. I reviewed risks of procedure which include but are not limited to bleeding, pneuomothorax, infection and need for blood transfusion. Alternatives to procedure are not available short of foregoing life saving diaysis treatments. Patient consented to procedure and had opportunity to ask questions.
Labs: INR and Plts were checked prior to procedure and were normal
Procedure: Using local anesthesia and sterile technique the left IJ vein was cannulated w/ a single stick without difficulty. Dark, non pulsatile blood was aspirated at which point using sterile seldinger method a double lumen dialysis catheter was inserted without difficulty to 12.5 CM. Dark, non-pulsatile blood was aspirated from all ports. Line was sutured in place and dressed. Patient tolerated procedure without complications. Follow up CXR to document location and rule out pneumothorax is pending. Mixed venous ABG to document venous placement is pending.
Signed: John Johnson, MD beeper 3030