Procedure Note 11
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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 and risks were explained
to the patient and that the patient consented: "The patient understands
the risks of the procedure and consents in writing."
Lab tests: Relevant labs, such as the INR and 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 labs tests which were
ordered.
Discharge Note
The discharge note should be written in the patient's chart prior to discharge.
Discharge Note
Date/time:
Diagnoses:
Treatment: Briefly describe therapy provided during hospitalization,
including antibiotic therapy, surgery, and cardiovascular drugs.
Studies Performed: Electrocardiograms, CT scan.
Discharge medications:
Follow-up Arrangements:
