Procedure sample documentation

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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 (Conious) 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