Procedure Note

A procedure note should be written in the chart when a procedure is performed. Procedure notes are brief operative notes.

Procedure Note

Date and time:

Procedure:

Indications:

Patient Consent: 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. Lab tests: Electrolytes, INR, CBC Anesthesia: Local with 2% lidocaine Description of Procedure: Briefly describe the procedure, including sterile prep, anesthesia method, patient position, devices used, anatomic location of procedure, and outcome.

Complications and Estimated Blood Loss (EBL): Disposition: Describe how the patient tolerated the procedure.

Specimens: Describe any specimens obtained and laboratory tests which were ordered.

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