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. ��

Ear FB

Foreign Body 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, 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: 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/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: 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

Epistaxis Mgmt 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 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

Eye FB removal

Foreign Body removal Eye 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 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 1 objects recovered. Post-procedure assessment: foreign body removed Patient tolerance: Patient tolerated the procedure well with no immediate complications. ��Comments:

Gtube replacement

G-Tube Placement 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: 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.

IJ

Central Line Performed by: DONALDSON, ROSS IRELAND Authorized by: DONALDSON, ROSS IRELAND 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 and guardian 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

Intubation Performed by: DONALDSON, ROSS I. Authorized by: DONALDSON, ROSS I. 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

IO Line Performed by: DONALDSON, ROSS I. Authorized by: DONALDSON, ROSS I. 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.