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/vessel loop placed

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:

Authorized by:

Consent: Verbal consent obtained.

Risks and benefits: risks, benefits and alternatives were discussed

Consent given by: patient

Patient or guardian understanding: States understanding of the procedure being performed

Patient or guardian consent: 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:

Authorized by:

Consent: Verbal consent obtained.

Risks and benefits: risks, benefits and alternatives were discussed

Consent given by: patient

Patient or guardian understanding: States understanding of the procedure being performed

Patient or guardian consent: 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.

Lumbar Puncture

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

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

Orthopedic Nerve Block (Finger)

Authorized 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: 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.

Orthopedic Reduction (Nursemaid's elbow)

Authorized by:

Consent: Verbal consent obtained.

Risks and benefits: risks, benefits and alternatives were discussed

Consent given by: Guardian

Patient understanding: Guardian states understanding of the procedure being performed

Patient consent: 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.

Ear Cleaning with Cerumen Removal and Placement of Ear Wick

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

Placement: Ear wick

Objects recovered: NA

Post-procedure assessment: copious discharge removed

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

Wound Care by MD (Packing Change)

Performed by:

Authorized by:

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

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

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

Comments: X liters removed without complication

Paraphymosis

Nerve Block (Penis)

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: 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:

Performed by:

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:

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

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.

Peritonsillar Abscess

Incision/Drainage of Peritonsillar Abscess

Performed by:

Authorized by:

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:

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: 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

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: 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

Authorized 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: 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 (Conscious) Sedation

Authorized by:

Performed by:

Consent: Written consent obtained (see nursing note)

Risks and benefits: risks, benefits and alternatives were discussed

Consent given by: patient

Patient understanding: states understanding of the procedure being performed

Patient consent: 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 Application and Check

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.

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:

Authorized by:

Consent: Verbal consent obtained.

Risks and benefits: risks, benefits and alternatives were discussed

Consent given by: patient

Patient understanding: states understanding of the procedure being performed

Patient consent: 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

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.

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:

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:

Authorized by:

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