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