These are sample procedure notes to help you do your documentation professionally during your residency. These notes include:
Thoracentesis
Intubation
PICC line
Subclavian CVC
Internal Jugular CVC
Internal Jugular CVC, U/S Guided
Femoral CVC
Paracentesis
Lumbar Puncture
Femoral A-line
Radial A-line
Pulmonary Artery Catheter
Transvenous Pacemaker
Bone Marrow Biopsy
PROCEDURE:
Thoracentesis, U/S guided.
INDICATION:
Large pleural effusion.
PROCEDURE OPERATOR:
CONSENT:
Consent was obtained from the patient (or next of kin) prior to the
procedure. Indications, risks, and benefits were explained at length.
PROCEDURE SUMMARY:
A time out was performed. The patient was prepped and draped in
a sterile manner using chlorhexidine scrub after the appropriate
level was percussed and confirmed by ultrasound. U/S images were
permanently documented. 1% lidocaine was used to numb the
region. A finder needle was then used to attempt to locate fluid;
however, a 22-gauge, 3 1/2-inch spinal needle was required to
actually locate fluid. Fluid was aspirated on the second attempt o
nly after completely hubbing the spinal needle.
Clear yellow fluid was obtained. A 10-blade scalpel used to make the
incision. The thoracentesis catheter was then threaded without
difficulty. The patient had 1200 mL of clear yellow fluid removed.
No immediate complications were noted during the procedure.
Dr. _____ was present during the entire procedure.
A post-procedure chest x-ray is pending at the time of this dictation.
The fluid will be sent for several studies.
ESTIMATED BLOOD LOSS: |
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PROCEDURE:
Endotracheal intubation.
INDICATIONS:
Respiratory distress.
PROCEDURE OPERATOR:
PROCEDURE SUMMARY:
Permit was implied secondary to emergent situation. A MAC 3
blade was inserted into the oropharynx at which time the
vocal cords were visualized. A 7.5-French endotracheal tube was
inserted and visualized going through the vocal cords. The stylette
was removed. Colorimetric change was visualized on the CO2 meter.
Breath sounds were heard in both lung fields equally.
The endotracheal tube was placed at 22 cm, measured at the teeth.
COMPLICATIONS:
ESTIMATED BLOOD LOSS: |
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PROCEDURE:
Non-tunneled peripherally inserted central catheter (PICC),
U/S guided.
INDICATION:
Need for long-term IV antibiotics.
PROCEDURE OPERATOR:
CONSENT:
Consent was obtained from the patient (or next of kin) prior to the
procedure. Indications, risks, and benefits were explained at length.
PROCEDURE SUMMARY:
A Time-Out was performed. The patient was then prepped and
draped in standard sterile fashion using chlorhexidine scrub.
Local anesthesia was achieved with 1%
lidocaine. The <LEFT/RIGHT> <BASILIC/BRACHIAL/
CEPHALIC> vein was accessed under ultrasound guidance
using a micropuncture needle. Ultrasound images were
permanently documented. The needle was then exchanged for
a 5-French coaxial dilator over a wire. A <SINGLE/DOUBLE>
lumen <5/6> french PICC line catheter was trimmed
to <___> cm and inserted through peel-away sheath.
The peel-away sheath was then removed, and the catheter was
secured to the skin with silk suture. At time of procedure
completion, the catheter flushed and aspirated easily. The patient
tolerated the procedure well without any immediate complication.
Postprocedure x-ray shows the tip of the catheter at the cavoatrial
junction.
ESTIMATED BLOOD LOSS: |
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PROCEDURE:
Subclavian central venous catheter.
INDICATION:
PROCEDURE OPERATOR:
CONSENT:
Consent was obtained from the patient (or next of kin) prior to the
procedure. Indications, risks, and benefits were explained at length.
PROCEDURE SUMMARY:
A time out was performed. The patient was placed in
Trendelenburg position. <LEFT/RIGHT> chest region was
prepped and draped in sterile fashion using chlorhexidine scrub.
Anesthesia was achieved with 1% lidocaine. The introducer
needle was inserted approximately two centimeters lateral
to the normal curvature of the patient's <LEFT/RIGHT>
clavicle. Venous blood was withdrawn. Syringe was removed
and a guidewire was advanced into the introducer needle. A small
incision was made at the skin surface with a scalpel and the
introducer needle was exchanged for a dilator over the guidewire.
After appropriate dilation was obtained, the dilator was
exchanged over the wire for an 8.5 French, quad-lumen, central
venous catheter. The wire was removed and the catheter was
sutured in place at <__> cm. The patient tolerated the
procedure without any hemodynamic compromise. At time
of procedure completion, all ports aspirated and flushed properly.
Post-procedure x-ray shows the tip of the catheter within the SVC.
Dr. ____ was present during all pertinent portions of the procedure.
ESTIMATED BLOOD LOSS: |
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PROCEDURE:
Internal jugular central venous catheter.
INDICATION:
PROCEDURE OPERATOR:
CONSENT:
Consent was obtained from the patient (or next of kin) prior to the
procedure. Indications, risks, and benefits were explained at length.
PROCEDURE SUMMARY:
A time-out was performed. The patient's <LEFT/RIGHT>
neck region was prepped and draped in sterile fashion. Anesthesia
was achieved with 1% lidocaine. The finder needle was inserted
into the <LEFT/RIGHT> neck at the location of the apex of the
triangle formed between the anterior and posterior bellies of the
sternocleidomastoid muscle, and venous blood was withdrawn. The
introducer needle was then inserted just adjacent to finder needle
and venous blood was withdrawn into the syringe. The syringe was
removed and the guidewire was advanced through the introducer
needle. A small incision was made with a scalpel and the
introducer needle was removed. A dilator was advanced over the
guidewire until appropriate dilation was obtained. The dilator was
removed and an 8.5 French central venous quad-lumen catheter
was advanced over the guidewire and secured into place with 4
sutures at <__> cm. At time of procedure completion, all
ports aspirated and flushed properly. Post-procedure x-ray shows
the tip of the catheter overlying the SVC.
COMPLICATIONS:
There was some ventricular ectopic activity noted during the course
of the procedure, which resolved within a few seconds after the
guidewire was withdrawn.
ESTIMATED BLOOD LOSS:
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PROCEDURE:
Internal jugular central venous catheter, U/S guided.
INDICATION:
PROCEDURE OPERATOR:
CONSENT: Consent was obtained from the patient (or next of kin)
prior to the procedure. Indications, risks, and benefits were
explained at length.
PROCEDURE SUMMARY:
A time-out was performed. The patient's <LEFT/RIGHT>
neck region was prepped and draped in sterile fashion using
chlorhexidine scrub. Anesthesia was achieved with 1% lidocaine.
The <LEFT/RIGHT> internal jugular vein was accessed
under ultrasound guidance using a finder needle and sheath.
U/S images were permanently documented. Venous blood was
withdrawn and the sheath was advanced into the vein and the
needle was withdrawn. A guidewire was advanced through the
sheath. A small incision was made with a 10 blade scalpel and
the sheath was exchanged for a dilator over the guidewire until
appropriate dilation was obtained. The dilator was removed
and an 8.5 French central venous quad-lumen catheter was
advanced over the guidewire and secured into place with 4
sutures at <__> cm. At time of procedure completion,
all ports aspirated and flushed properly. Post-procedure x-ray
shows the tip of the catheter within the superior vena cava.
COMPLICATIONS:
ESTIMATED BLOOD LOSS: |
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PROCEDURE:
Femoral central venous catheter
INDICATION:
Need for intravenous access due to septic shock
PROCEDURE OPERATOR:
CONSENT:
Consent was implied due to the emergent nature of the procedure.
PROCEDURE SUMMARY:
The patient was prepped and draped in the usual sterile manner
using chlorhexidine scrub. 1% lidocaine was used to numb the
region. The finder needle was used to locate the
<LEFT/RIGHT> femoral vein. A quad-lumen 8.5 French
20 cm catheter was inserted using the Seldinger technique. All
ports aspirate and flushed without difficulty. The patient tolerated
the procedure well without any immediate complications. The line
was sutured into place and the area was cleaned and Tegaderm
applied. Dr. ____ was present during the procedure.
ESTIMATED BLOOD LOSS: |
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PROCEDURE:
Diagnostic & Therapeutic Paracentesis, U/S guided.
INDICATION:
Worsening ascites.
PROCEDURE OPERATOR:
CONSENT:
Consent was obtained from the patient (or next of kin) prior to the
procedure. Indications, risks, and benefits were explained at length.
PROCEDURE SUMMARY:
A time-out was performed. The area of the <LEFT/RIGHT>
abdomen was prepped and draped in a sterile fashion using
chlorhexidine scrub. 1% lidocaine was used to numb the region.
The skin was incised 1.5 mm using a 10 blade scalpel. The
paracentesis catheter was inserted and advanced with negative
pressure under ultrasound guidance. Ultrasound images were
permanently documented. No blood was aspirated. Clear
yellow fluid was retrieved and collected. Approximately 65 mL
of ascitic fluid was collected and sent for laboratory analysis.
The catheter was then connected to the vaccutainer and <__>
liters of additional ascitic fluid were drained. The catheter was
removed and no leaking was noted. 50 g of albumin was
intravenously during the procedure. The patient tolerated the
procedure well without any immediate complications.
Dr. ____ was present during the procedure.
ESTIMATED BLOOD LOSS: |
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PROCEDURE:
Lumbar Puncture.
INDICATION:
Altered mental status and fever.
PROCEDURE OPERATOR:
CONSENT:
Consent was obtained from the patient (or next of kin) prior to the
procedure. Indications, risks, and benefits were explained at length.
PROCEDURE SUMMARY:
A time-out was performed. The patient was placed in the
<LEFT/RIGHT> lateral decubitus position in a semi-fetal
position with help from the nursing staff. The area was
cleansed and draped in usual sterile fashion. Anesthesia was
achieved with 1% lidocaine. A 20-gauge 3.5-inch spinal needle
was placed in the L4-L5 interspace. On the first attempt, clear
cerebral spinal fluid was obtained. Four tubes were filled with
4 mL of CSF. These were sent for the usual tests, including 1
tube to be held for further analysis if needed. The patient had no
immediate complications and tolerated the procedure well.
Dr. ____ was present during the entire procedure.
ESTIMATED BLOOD LOSS: |
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PROCEDURE:
Femoral artery line placement. (A-line)
INDICATION:
PROCEDURE OPERATOR:
CONSENT:
Consent was obtained from the patient (or next of kin) prior to the
procedure. Indications, risks, and benefits were explained at length.
PROCEDURE SUMMARY:
The patient was prepped and draped in the usual sterile manner
using chlorhexidine scrub. 1% lidocaine was used to numb the
region. The <LEFT/RIGHT> femoral artery was accessed
using a needle. Pulsatile, arterial blood was visualized and the
artery was then threaded using the Seldinger technique and a
catheter was then sutured into place. Good wave-form was
obtained. The patient tolerated the procedure well without any
immediate complications. The area was cleaned and Tegaderm
was applied. Dr. ____ was present during the entire procedure.
ESTIMATED BLOOD LOSS: |
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PROCEDURE:
Radial artery line placement. (A-line)
INDICATION:
PROCEDURE OPERATOR:
CONSENT:
Consent was obtained from the patient (or next of kin) prior to the
procedure. Indications, risks, and benefits were explained at length.
PROCEDURE SUMMARY:
The patient was prepped and draped in the usual sterile manner
using chlorhexidine scrub. 1% lidocaine was used to numb the
region. The <LEFT/RIGHT> radial artery was palpated and
successfully cannulated on the first pass. Pulsatile, arterial blood
was visualized and the artery was then threaded using the Seldinger
technique and a catheter was then sutured into place.
Good wave-form was obtained. The patient tolerated the
procedure well without any immediate complications. The area
was cleaned and Tegaderm was applied. Dr. ____ was present
during the entire procedure.
ESTIMATED BLOOD LOSS: |
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PROCEDURE:
Pulmonary Artery Catheter (Swan-Ganz)
INDICATION:
Shock, of unknown etiology.
PROCEDURE OPERATOR:
CONSENT:
Consent was obtained from the patient (or next of kin) prior to the
procedure. Indications, risks, and benefits were explained at length.
PROCEDURE SUMMARY:
The patient was prepped and draped in the usual sterile manner.
The Swan-Ganz catheter was tested. It was then inserted into
the <LEFT/RIGHT> internal jugular central venous catheter.
At approximately 15-cm the balloon was inflated and slowly
advanced. Appropriate wave forms were obtained, both for right
atrium, right ventricle, pulmonary artery and pulmonary wedge.
Wave forms were all visualized. The patient had a PA pressure
of <__>, pulmonary wedge pressure of <__>, central
venous pressure of <__>, cardiac output <__> and
SCR was <__>. From this data, it was
determined that the patient was in <SEPTIC/CARDIOGENIC>
shock.
COMPLICATIONS:
ESTIMATED BLOOD LOSS:
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PROCEDURE:
Transvenous pacemaker.
INDICATION:
Bradycardia unresponsive to atropine.
PROCEDURE OPERATOR:
CONSENT:
Consent was obtained from the patient (or next of kin) prior to the
procedure. Indications, risks, and benefits were explained at length.
PROCEDURE SUMMARY:
Using the previously placed <LEFT/RIGHT> internal jugular
catheter, a bipolar pacing catheter was advanced into the Cordis.
The catheter was advanced to approximately 15 centimeters
whereupon the balloon was inflated. It was further advanced into
the right atrium and then the right ventricle to a depth of
<__> cm at which point pacing was achieved. The balloon
was deflated and the catheter was retracted <__> cm.
The pacer was then advanced an additional <__> cm and
capture was reachieved at <__> mAmp. The patient
tolerated the procedure well with no immediate complications.
Dr. ____ was present during the entire procedure.
ESTIMATED BLOOD LOSS:
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PROCEDURE:
Bone marrow aspirate and biopsy.
INDICATION:
Pancytopenia.
PROCEDURE OPERATOR: CONSENT:
Consent was obtained from the patient (or next of kin) prior to the
procedure. Indications, risks, and benefits were explained at length.
PROCEDURE SUMMARY:
The patient was laid in the <LEFT/RIGHT> lateral
decubitus position. The <LEFT/RIGHT> posterior superior
iliac spine was prepped and draped in a sterile fashion. The patient
was premedicated with 10 mg of morphine sulfate IV and 1 mg
of Ativan IV. The crest of the posterior superior iliac spine was
located, and the skin as well as the surface of the bone was
anesthetized with 1% lidocaine. A Kelly needle was introduced,
and bone marrow aspirate was obtained without any difficulty.
This was withdrawn, and the Jamshidi needle was advanced into
the bone cavity. A bone marrow biopsy was obtained without any
complications. Dr. ___ was present for the critical part of the
procedure.
COMPLICATIONS:
ESTIMATED BLOOD LOSS: |
