Documentation of Procedures

Question 1

Define memory aid

Answer 1

Assists clinician in recalling important findings, techniques used, or complications encountered during procedure

Question 2

What is included in a procedure note?

Answer 2

1. Date and Start Time of Procedure
2. Pt name, age, DOB:*
3. Procedure performed
4. Consent
5. Indication
6. Contraindications
7. Physician/PA
8. Anesthesia: (if any)
9. Description of Procedure: State how you performed procedure from start to finish (think about what steps you took to accomplish the task) See posted example of procedure note in BB.
10. Complications: (includes EBL, side effects, and adverse rxns, if any)
11. Instructions and follow up plans:
12. Time procedure completed and condition of pt (or Disposition) :
13. Sign note with PAS I (now) PAS II (after Aug.)

Question 3

What are examples of procedures that involve clinical procedures?

Answer 3

1. Laceration Repair
2. Lumbar puncture
3. NG tube insertion
4. I&D of abscess
5. Cryosurgery
6. Chest tube placement
7. Thoracocentesis
8. Intra-articular injections
9. Endoscopy
10. Colonoscopy
11. Removal of any drains or tubes should also have documentation