Procedure Note Templates
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Central Venous
Catheter Insertion
Indication:
Type of Procedure: Central Venous Catheter Placement
Attending Physician:
Assisting Physician:
Consent: Detailed explanation of the procedure, treatment options, risks including but not limited to infection and bleeding, and benefits were explained to the patient (or family). A written informed consent was obtained.
Technique: A time out was preformed identifying the correct procedure, the correct location with the nursing staff. The right/left neck / chest / groin was prepped with 2% chlorhexidine and draped with a full length sterile sheet in the usual fashion. 1% lidocaine was administered subcutaneously for local anesthesia. The right/left internal jugular/subclavian/femoral vein was accessed under ultrasound guidance with an 18 gauge thin wall needle. A triple lumen/double lumen/ 9 french cordis/MAC was inserted via the seldinger technique. Blood was withdrawn from all lumens and flushed with normal saline. The catheter was sutured in place and a sterile dressing was applied over the site prior to removal of drapes.
The patient tolerated the procedure well and there were no complications.
Chest x ray is pending at this time.
EBL:
Complication: None
Indication:
Type of Procedure: Arterial Line Placement
Attending Physician:
Resident:
Universal Protocol: a time out was performed and the correct patient and site were verified
Consent: the risks and benefits of arterial line placement discussed with the
patient/family, including the risk of bleeding, infection, and technical failure. The risks of not performing the procedure, less accurate hemodynamic monitoring and inability to accurately titrate medications, discussed with the patient/family. The alternatives of performing the procedure, noninvasive blood pressure monitoring, also discussed. The patient/family consented to the procedure.
Anesthesia was obtained with [ ] ml [1% lidocaine]. The [L/R] [wrist] was prepped in the usual sterile fashion. The [ radial/ulnar/brachial/femoral/dorasalis pedis ] artery was cannulated and a 20g Arrow catheter was placed over a wire. Appropriate wave form was noted. The line was secured with sutures. A dressing was placed over the site. The patient tolerated the procedure well. Extremity with good capillary refill and neurovascularly intact distal to arterial cannulization site.
Complications: [none]
Estimated Blood Loss: [minimal]
Arterial Line Placement
Chest Tube Insertion
Indication:
Type of Procedure: Chest Tube Insertion
Attending Physician:
Resident:
A time-out was completed and placed in paper chart. The patient was positioned appropriately for chest tube placement. The patient’s right / left chest was prepped and draped in sterile fashion. 1% Lidocaine was/not used to anesthetize the surrounding skin area. A 2 cm skin incision was made in the mid-axillary line at the inframammary crease. Utilizing blunt dissection a subcutaneous tunnel was created cephalad just adjacent to the superior rib. The pleural space was entered bluntly and gush of air/blood was observed. A finger was inserted into the pleural space to check for anatomy and guide tube insertion. A 36/40F thoracostomy tube was inserted using a Kelly clamp and positioned appropriately. The chest tube was sutured securely to the skin and a sterile dressing applied. A pleurevac was attached to the chest tube and a chest x-ray obtained.
Complications: [none]
Estimated Blood Loss: [minimal]
Incision & Drainage
Indication:
Type of Procedure: Incision and Drainage
Attending Physician:
Resident:
Patient positioned appropriately, __cc lidocaine with/without epinephrine was used as a local anesthetic. #11 blade scalpal used for single incision. Additional local anesthetic injected into surrounding viable tissue prior to blunt dissection of loculated adhesions. Copius drainage of pus (culture obtained). Wound packed with iodoform gauze. Wound dressed with sterile 4x4 guaze and paper tape.
Complications: [none]
Estimated Blood Loss: [minimal]
Wound Closure
Indication:
Type of Procedure: Wound Closure
Attending Physician:
Resident:
Patient was positioned appropriately, ___cc lidocaine with/without epinephrine was used as a local anesthetic. 500cc NaCl was used for irrigation. Patient was sterile draped with wound exposed. __x _.0 nylon sutures were placed with good approximation. Procedure tolerated without complications. Wound dressed with bacitracin and sterile gauze.