Procedure sample documentation

Abscess drainage (Incision/Drainage)

Performed by:

Authorized by:

Consent: Verbal 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

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:

Authorized by:

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

Performed by:

Authorized by:

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

Performed by:

Authorized by:

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.

Ear Foreign Body

Performed by:

Authorized by:

Consent: Verbal consent obtained.

Risks and benefits: risks, benefits and alternatives were discussed

Required items: required blood products, implants, devices, and special equipment available

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.

Body area: ear

Localization method: visualized

Removal mechanism: ear scoop, alligator forceps and balloon extraction, irrigation

Complexity: complex

Objects recovered: 1

Post-procedure assessment: foreign body removed

Patient tolerance: Patient tolerated the procedure well with no immediate complications

EJ

External Jugular Vein Access

Performed by:

Authorized by:

Consent: Verbal 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

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.

Indications: vascular access

Preparation: skin prepped with 2% chlorhexidine

Skin prep agent dried: skin prep agent completely dried prior to procedure

Location details: right external jugular

Patient position: Trendelenburg

Catheter type: IV catheter

Pre-procedure: landmarks identified

Successful placement: yes

Post-procedure: dressing applied

Assessment: blood return and free fluid flow

Patient tolerance: Patient tolerated the procedure well with no immediate complications.

Epistaxis

Performed by:

Authorized by:

Consent: Verbal 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

Required items: required blood products, implants, devices, and special equipment available

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.

Treatment site: right anterior and right posterior

Repair method: nasal balloon

Post-procedure assessment: bleeding stopped

Treatment complexity: simple

Patient tolerance: Patient tolerated the procedure well with no immediate complications

Foreign Body Removal: Eye

Performed by:

Authorized by:

Consent: Verbal 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

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.

Body area: eye

Local anesthetic: tetracaine drops

Anesthetic total: 1 drop

Patient cooperative: yes

Localization method: slit lamp

Removal mechanism: moist cotton swab

Eye examined with fluorescein.

Complexity: simple

Objects recovered: 1

Post-procedure assessment: foreign body removed

Patient tolerance: Patient tolerated the procedure well with no immediate complications.

Comments:

G-Tube Placement/Replacement

Authorized by:

Performed by:

Consent: Verbal consent obtained.

Risks and benefits: risks, benefits and alternatives were discussed

Consent given by: patient and/or guardian

Patient understanding: patient/guardian states understanding of the procedure being performed

Patient consent: the patient/guardian'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.

Location details: abdomen

Procedure: using gentle pressure, new g-tube was placed with normal saline injected afterward to fill balloon port

Results: KUB with contrast confirms proper placement

Complication: Tolerated well without complication.

Central Line: IJ

Performed by:

Authorized by:

Consent: Verbal consent obtained. The procedure was performed in an emergent situation.

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

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.

Indications: vascular access and central pressure monitoring

Anesthesia: local infiltration

Local anesthetic: lidocaine 2% with epinephrine

Anesthetic total: 4 ml

Preparation: skin prepped with 2% chlorhexidine

Skin prep agent dried: skin prep agent completely dried prior to procedure

Sterile barriers: all five maximum sterile barriers used - cap, mask, sterile gown, sterile gloves, and large sterile sheet

Hand hygiene: hand hygiene performed prior to central venous catheter insertion

Location details: right internal jugular

Patient position: Trendelenburg

Catheter type: triple lumen

Pre-procedure: landmarks identified

Ultrasound guidance: yes

Number of attempts: 1

Successful placement: yes

Post-procedure: line sutured and dressing applied

Assessment: blood return through all parts, free fluid flow, placement verified by x-ray and no pneumothorax on x-ray

Patient tolerance: Patient tolerated the procedure well with no immediate complications.

Intubation

Performed by:

Authorized by:

Consent: Verbal consent not obtained. The procedure was performed in an emergent situation.

Required items: required blood products, implants, devices, and special equipment available

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.

Indications: respiratory failure and airway protection

Intubation method: direct

Patient status: paralyzed (RSI)

Preoxygenation: BVM and nonrebreather mask

Sedatives: etomidate

Paralytic: succinylcoline

Laryngoscope size: Mac 4

Tube size: 7.5 mm

Tube type: cuffed

Number of attempts: 1

Cords visualized: yes

Post-procedure assessment: chest rise, BS = bilaterally none over epigastrum, +CO2 detector

Breath sounds: equal and absent over the epigastrium

Cuff inflated: yes

ETT to lip: 22 cm

Tube secured with: adhesive tape

Chest x-ray interpreted by me.

Chest x-ray findings: endotracheal tube in appropriate position

Patient tolerance: Patient tolerated the procedure well with no immediate complications.

IO Line Placement

Performed by:

Authorized by:

Consent: The procedure was performed in an emergent situation.

Risks and benefits: risks, benefits and alternatives were discussed

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.

Indications: rapid vascular access

Insertion site: right proximal tibia

Site preparation: chlorhexidine

Insertion device: drill device

Insertion: needle was inserted through the bony cortex

Number of attempts: 1

Confirmation method: stability of the needle, easy infusion of fluids and aspiration of blood/marrow

Secured with: protective shield

Patient tolerance: Patient tolerated the procedure well with no immediate complications

Laceration

Dermabond

Lac Repair (with Dermabond) Performed by: DONALDSON, ROSS IRELAND Authorized by: DONALDSON, ROSS IRELAND Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient or guardian Patient or guardian understanding: patient or guardian

states understanding of the procedure being performed

Patient or guardian consent: the patient or guardian's understanding of the procedure matches consent given 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. Body area: X Laceration length: X cm Foreign bodies: no foreign bodies Tendon involvement: none Nerve involvement: none Vascular damage: no Anesthesia: local infiltration Local anesthetic: none Anesthetic total: 0 ml Patient sedated: no Preparation: Patient was prepped and draped in the usual sterile fashion. Irrigation solution: saline Irrigation method: jet lavage and syringe Amount of cleaning: extensive Debridement: none Degree of undermining: none Skin closure: Dermabond Number of sutures: NA Technique: simple Approximation: close Approximation difficulty: simple Dressing: antibiotic ointment/4x4 gauze Patient tolerance: Patient tolerated the procedure well with no immediate complications.

Standard

Lac Repair Performed by: DONALDSON, ROSS IRELAND Authorized by: DONALDSON, ROSS IRELAND Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient or guardian Patient or guardian understanding: patient or guardian

states understanding of the procedure being performed

Patient or guardian consent: the patient or guardian's understanding of the procedure matches consent given 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. Body area: X Laceration length: X cm Foreign bodies: no foreign bodies Tendon involvement: none Nerve involvement: none Vascular damage: no Anesthesia: local infiltration Local anesthetic: lidocaine with epinephrine Anesthetic total: 4 ml Patient sedated: no Preparation: Patient was prepped and draped in the usual sterile fashion. Irrigation solution: saline Irrigation method: jet lavage and syringe Amount of cleaning: extensive Debridement: none Degree of undermining: none Skin closure: 6-0 nylon Number of sutures: X Technique: interupted Approximation: close Approximation difficulty: simple Dressing: antibiotic ointment/4x4 gauze Patient tolerance: Patient tolerated the procedure well with no immediate complications.

Staples

Lac Repair with Staples Performed by: DONALDSON, ROSS IRELAND Authorized by: DONALDSON, ROSS IRELAND Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient or guardian Patient or guardian understanding: patient or guardian

states understanding of the procedure being performed

Patient or guardian consent: the patient or guardian's understanding of the procedure matches consent given 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. Body area: scalp Laceration length: X cm Foreign bodies: no foreign bodies Tendon involvement: none Nerve involvement: none Vascular damage: no Anesthesia: local infiltration Local anesthetic: lidocaine with epinephrine Anesthetic total: 4 ml Patient sedated: no Preparation: Patient was prepped and draped in the usual sterile fashion. Irrigation solution: saline Irrigation method: jet lavage and syringe Amount of cleaning: extensive Debridement: none Degree of undermining: none Skin closure: Staples Number of staples: X Technique: simple Approximation: close Approximation difficulty: simple Dressing: antibiotic ointment/4x4 gauze Patient tolerance: Patient tolerated the procedure well with no immediate complications.

LP

Procedures Lumbar Puncture Performed by: DONALDSON, ROSS IRELAND Authorized by: DONALDSON, ROSS IRELAND 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 Relevant documents: relevant documents present and verified Test results: test results available and properly labeled Site marked: the operative site was marked Imaging studies: imaging studies 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. Anesthesia: local infiltration Local anesthetic: lidocaine 1% without epinephrine Anesthetic total: 4 ml Patient sedated: no Preparation: Patient was prepped and draped in the usual sterile fashion. Lumbar space: L4-L5 interspace Patient's position: lateral decubitus Needle gauge: 22 Number of attempts: 1, atraumatic Opening pressure: XX cm H2O Fluid appearance: clear Tubes of fluid: 4 Total volume: 4 ml Post-procedure: site cleaned and pressure dressing applied Patient tolerance: Patient tolerated the procedure well with no immediate complications. Comments: Nontraumatic

Nerve block

Orthopedic Nerve Block (Finger) Authorized by: DONALDSON, ROSS IRELAND Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given 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. Location details: XXX finger Injection: using standard, sterile technique 4 cc of lidocaine without epinepherine injected Complication: Tolerated well without complication.

Nursemaid's

Orthopedic Reduction (Nursemaid's elbow) Authorized by: DONALDSON, ROSS IRELAND Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given 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. Location details: arm Reduction Procedure: gentle flexion/supination followed by extension/pronation Results: After procedure, the patient was able to move the arm fully without pain. No TTP. Issue fully resolved and patient back to normal. Complication: Tolerated well without complication. DNVI.

Otitis externa cleaning

Ear Cleaning with Cerumen Removal and Placement of Ear Wick Performed by: DONALDSON, ROSS I. Authorized by: DONALDSON, ROSS I. Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Required items: required blood products, implants, devices, and special equipment available 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. Body area: ear Localization method: visualized Removal mechanism: ear scoop Placement: Ear wick Objects recovered: NA Post-procedure assessment: copious discharge removed Patient tolerance: Patient tolerated the procedure well with no immediate complications

Abscess packing change

Wound Care by MD (Packing Change) 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. Wound treatment: packing changed Patient tolerance: Patient tolerated the procedure well with no immediate complications.

Paracentesis

Abdominal Paracentesis 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 Patient tolerance: Patient tolerated the procedure well with no immediate complications. Comments: X liters removed without complication

Paraphymosis

Nerve Block (Penis) Authorized by: DONALDSON, ROSS IRELAND Performed by: DONALDSON, ROSS IRELAND Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given 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. Location details: penis Injection: using standard, sterile technique 8 cc of lidocaine without epinepherine injected circumferentially Complication: Tolerated well without complication.

Reduction of Paraphimosis Authorized by: DONALDSON, ROSS IRELAND Performed by:: DONALDSON, ROSS IRELAND Consent: Written consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given 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. Location details: penis Reduction Procedure: Slow direct pressure first applied; followed by reduction using direct pressure Results: After procedure, fully reduced. Complication: Tolerated well without complication.

Paronychia

Incision/Drainage of Paronychia 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 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 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. Type: abscess Body area: upper extremity Location details: XX finger Anesthesia: nerve block Local anesthetic: lidocaine 1% without epinephrine Anesthetic total: 4 ml Incision type: single straight Complexity: simple Drainage: purulent Drainage amount: mod Wound treatment: drain placed Packing material: 1/4 in gauze Patient tolerance: Patient tolerated the procedure well with no immediate complications. Comments: With iris sissors, dissected along top of nail.

PTA

Incision/Drainage of Peritonsillar Abscess 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: peritonsilar abscess Location details: right Anesthesia: local infiltration and spray Local anesthetic: lidocaine 1% with epinephrine and benzocaine spray Anesthetic total: 2 ml Patient sedated: no Incision type: straight puncture to 1.5 cm with spinal needle covered by plastic cover Attempts: 3 Drainage: purulent drainage Drainage amount: 5cc Patient tolerance: Patient tolerated the procedure well with no immediate complications.

Digit reduction

Orthopedic Reduction (Digit) Authorized by: DONALDSON, ROSS IRELAND Performed by: DONALDSON, ROSS IRELAND Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given 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. Location details: X Reduction Procedure: gentle hyperextension and axial pull Results: After procedure, digit was fully mobile Complication: Tolerated well without complication. <2sec CRT. Tendons intact.

Fracture reduction

Orthopedic Reduction of Fracture Authorized by: DONALDSON, ROSS IRELAND Performed by: DONALDSON, ROSS IRELAND Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given 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. Location details: ? Reduction Procedure: axial pull and closed manipulation Results: Post reduction alignement improved Complication: Tolerated well without complication. <2sec CRT. Tendons intact.

Hernia reduction

Reduction of Hernia Authorized by: DONALDSON, ROSS IRELAND Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given 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. Location details: XX hernia Reduction Procedure: Direct pressure, constant Results: After procedure, fully reduced. No TTP. Complication: Tolerated well without complication.

Procedural sedation

Conscious Sedation Authorized by: DONALDSON, ROSS IRELAND Performed by: DONALDSON, ROSS IRELAND Consent: Written consent obtained (see nursing note) Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given 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. Medication IV: XXX Complication: Tolerated well without complication. No hypoxic episodes. Time: Total intra-service time with patient was 17 minutes.

Splint check

Splint Application and Check Authorized by: DONALDSON, ROSS IRELAND Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and parent 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: 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. Location details: XX Post-procedure: The splinted body part was neurovascularly unchanged following the procedure. Patient tolerance: Patient tolerated the procedure well with no immediate complications.

Subungal hematoma

Incision/Drainage of Subungual Hematoma 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: NA Patient sedated: no Incision type: single with electric cautery Complexity: simple Drainage: blood Drainage amount: moderate Wound treatment: dressed Patient tolerance: Patient tolerated the procedure well with no immediate complications.

Suture removal

Suture Removal Performed by: ED Technician Authorized by: DONALDSON, ROSS IRELAND Consent: Verbal 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 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. Body area: XXX Wound Appearance: clean Post-removal: Steri-Strips applied and antibiotic ointment applied Patient tolerance: Patient tolerated the procedure well with no immediate complications.

Ingrown toenail

Orthopedic Nerve Block (toe) Authorized by: DONALDSON, ROSS IRELAND Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given 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. Location details: xxx Injection: using standard, sterile technique 4 cc of lidocaine without epinepherine injected to cover all 4 nerves (2 injections) Complication: Tolerated well without complication.

Toenail Removal 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: ingrown toenail Location details: xxx Procedure: Below toenail blunt dissected with kelly to base. Then, peripheral nail clamped and torqued until linear break to base of nail including growth area, and removed. Complication: None Wound treatment: 4x4 Patient tolerance: Patient tolerated the procedure well with no immediate complications.

See Also

• Documentation for emergency physicians