Procedure sample documentation
Abscess drainage
Incision/Drainage Performed by: DONALDSON, ROSS I. Authorized by: DONALDSON, ROSS I. Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and guardian Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Type: abscess Location details: xxx Anesthesia: local infiltration Local anesthetic: lidocaine 1% with epinephrine Anesthetic total: 15 ml Patient sedated: no Scalpel size: 11 Incision type: single straight Complexity: simple Drainage: purulent Drainage amount: moderate Wound treatment: packed Packing material: iodaform Patient tolerance: Patient tolerated the procedure well with no immediate complications. �
Abscess repacking
Abscess Repacking by MD Performed by: DONALDSON, ROSS I. Authorized by: DONALDSON, ROSS I. Consent: Verbal consent obtained. Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Type: abscess Location details: xxx Wound treatment: packed with gauze Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Arthrocentesis
Arthrocentesis Performed by: DONALDSON, ROSS I. Authorized by: DONALDSON, ROSS I. Consent: Verbal consent obtained. Written consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Procedure consent: procedure consent matches procedure scheduled Required items: required blood products, implants, devices, and special equipment available Patient identity confirmed: arm band and verbally with patient Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Preparation: Patient was prepped and draped in the usual sterile fashion. Local anesthesia used: yes Anesthesia: local infiltration Local anesthetic: lidocaine 1% without epinephrine Anesthetic total: 4 ml Patient sedated: no Location: knee Technique: medial approach Patient tolerance: Patient tolerated the procedure well with no immediate complications. Comments: X ccs removed without complication
Cardioversion
Cardioversion Performed by: DONALDSON, ROSS I. Authorized by: DONALDSON, ROSS I. Consent: Verbal consent obtained. Written consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Procedure consent: procedure consent matches procedure scheduled Required items: required blood products, implants, devices, and special equipment available Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Sedation type: moderate (conscious) sedation Sedatives: propofol Analgesia: fentanyl Vitals: Vital signs were monitored during sedation. Pre-procedure rhythm: atrial fibrillation Patient position: patient was placed in a supine position Chest area: chest area exposed Electrodes: pads Electrodes placed: anterior-posterior Number of attempts: 1 Attempt 1 mode: synchronous Attempt 1 shock (in Joules): 150 Post-procedure rhythm: normal sinus rhythm Complications: no complications Patient tolerance: Patient tolerated the procedure well with no immediate complications. ��
