36+ Sample Procedure Note
What Is a Procedure Note?
A procedure note is a legal document that serves as a record of a medical procedure that is added to a patient’s chart once the procedure is completed. Procedure notes are important because they clearly show which procedures were performed on a patient with consent, when they were performed, and what the results of these procedures were. Furthermore, by clearly and concisely recording relevant data about procedures, they protect hospitals and doctors from legal ramifications. Procedure note templates may be used by doctors based in the same hospital in some cases to ensure consistency.
What Are the Parts/Elements Of a Procedure Note?
As stated earlier, a procedure note is required on all medical procedures that require a patient’s consent. This document should also be written as soon as the medical procedure that was performed on the patient has been concluded. Here are the necessary parts that should be included when writing one:
- Date of the procedure – this element states the date when the medical procedure was performed on the patient.
- Time of the procedure – in addition to the date, the time of the said medical procedure should also be indicated on the procedure note.
- Name of the procedure being done – considered as one of the most important elements of this document, this part should state the name of the medical procedure that is to be performed on the patient.
- Indications – an indication is defined as the valid reason to use a certain test, medication, medical procedure, or surgery on the patient. There can be multiple indications listed in this document.
- Patient consent – in this part of the procedure note, the doctor or surgeon should document that the patient was informed about the procedure’s indications, risks, and alternatives. It should also be noted that the patient was given the opportunity to ask questions and that he or she signed off on the procedure in writing.
- Laboratory values and results – this element of the procedure note should state the results of the medical laboratory examinations that were conducted on the patient prior to the start of the medical procedure, as well as the laboratory values that prove that the medical procedure was done in a safe manner.
- Anesthetics – this part of the procedure note should indicate any types of anesthetics to be used on the patient during the medical procedure, if applicable.
- Description of the procedure – also considered as one of the most important parts of the procedure note, this should state in detail the description of the medical intervention/surgery that is to be performed on the patient. Details can be the standard position needed for the procedure and the medical devices and techniques being used.
- Complications – this part of the procedure note indicates any complications that have arised after the medical procedure was performed on the patient.
- Estimated Blood Loss – an estimate of how much blood that was lost during the procedure should also be noted, if applicable.
- Patient Disposition – disposition refers to the status of the patient at the conclusion of the medical procedure.
- Signature – the final part of the procedure note, this indicate’s the doctor’s name, title, license number, and the doctor’s signature. By signing the document, the procedure note will then have legal implications should any problems arise.
Common Types of Surgical Procedures
Here is a list of the common types of surgical procedures that a general surgeon can do:
Appendectomy. An appendectomy is a surgical procedure that removes the appendix. The appendix refers to a small pouch that connects to the large intestine. Appendicitis, an infection or inflammation of the appendix, is treated with an appendectomy. This surgery is also used to treat appendix tumors. Breast Biopsy. A biopsy is a diagnostic test that involves the removal of tissue or cells for examination under a microscope. This procedure is also used to remove abnormal breast tissue. A biopsy may be performed using a hollow needle to extract tissue (such as needle biopsy), or a lump may be partially or completely removed (lumpectomy) for examination and/or treatment.Coronary Artery Bypass. This surgery, also known as “bypass surgery,” is commonly performed in people who have angina (chest pain) and coronary artery disease (where plaque has built up in the arteries). A bypass is created during surgery by grafting a piece of a vein above and below the blocked area of a coronary artery, allowing blood to flow around the obstruction. Veins from the leg are typically used, but arteries from the chest may also be used to create a bypass graft. Esophageal Surgery. The esophagus is the hollow tube that connects your mouth and stomach. Because the esophagus is so important in digestion, esophageal problems can have an impact on nutritional intake and overall quality of life. Many esophageal diseases are treatable with medication, but some require surgery. Acid reflux surgery, esophagectomy, and esophageal lesion excision are all common esophageal surgeries. Gallbladder Removal. Gallbladder removal, also known as cholecystectomy, is a surgical procedure that removes the gallbladder. The gallbladder refers to the organ that helps with digestion. It stores the fluid (bile) produced by your liver to aid in the breakdown of fat. Cholecystectomy is a surgical procedure used to treat gallstones, gallbladder inflammation or infection, and gallbladder cancer.Free skin graft. A skin graft is the removal of healthy skin from one part of the body in order to repair areas of lost or damaged skin in another. Burns, injury, or surgical removal of diseased skin are all common reasons for skin grafts. They are typically used when the area is too large to be repaired with stitching or natural healing.Hernia Repair. The surgical correction of a hernia is known as hernia repair. When an organ or other structure protrudes through a weak area in tissue or muscle, it causes a hernia. Hernias can cause a visible lump to form in the chest, thigh, groin, or belly button. During a hernia repair, surgeons replace the protruding organ and then repair the weakened muscle or tissue.Varicose Vein Removal. A general surgeon can remove varicose veins that are thick and twisted and protrude through the skin. This common condition most commonly affects the feet and legs. Varicose veins are uncomfortable and can increase the risk of blood clots and skin sores. Doctors now frequently use a procedure that removes the swollen veins through one or more small incisions.Thyroid Removal. The thyroid gland is located at the base of your neck in the front. This gland produces hormones that are essential for metabolism. The thyroid gland can be affected by a variety of diseases. When infected, the thyroid gland may swell, making it difficult to breathe or swallow. It could also be overactive and produce an excessive amount of a certain hormone. The most common reason for thyroid gland surgery is cancer. A general surgeon may remove all or part of your thyroid depending on your condition. If your entire thyroid gland is removed, you will need to take synthetic hormones to replace the ones produced by the gland.Spleen Removal. The spleen is an organ on the left side of your body, next to your stomach. It performs a number of critical functions. It annihilates damaged blood cells. It aids in infection prevention. It also aids in the proper clotting of your blood. These functions are impaired when the spleen is enlarged. This increases your chances of becoming infected. A swollen spleen, on the other hand, has the potential to rupture and cause dangerous internal bleeding. When necessary, a general surgeon is trained to remove the spleen.
What Are the Risks Involved During Surgery?
Here are the common risks that can arise during a surgical procedure:
Bleeding Problems. While some bleeding is to be expected during surgery, excessive bleeding may necessitate a transfusion. If the bleeding is severe enough to cause a crisis, the surgery may be halted or a large transfusion may be required. Some religions prohibit blood transfusions, which must be discussed with the surgeon before scheduling a procedure. Bloodless surgery, which involves performing a surgical procedure without the use of blood products, is becoming more common by the year.Delayed Healing. Some patients heal more slowly than others, especially those who have multiple illnesses. A patient who has a chronic illness, an immune system problem, or is sick in the weeks leading up to surgery may have a longer hospital stay and a more difficult recovery period. Diabetics who have surgery typically have a longer recovery time, particularly if their blood sugar levels are poorly controlled. As a result, diabetics must carefully weigh the risks and benefits of undergoing surgery, including the possibility of complications during recovery.Breathing Difficulties. At the end of surgery, most patients can be removed from the breathing machine, also known as a ventilator. Some patients may require the ventilator for an extended period of time. In extreme cases, patients must be transferred to a rehabilitation facility to strengthen their breathing until they can be completely removed from the ventilator. Patients with pulmonary diseases, smokers, chronically ill patients, and those who required ventilator support prior to surgery are at the highest risk of remaining on the ventilator and receing further medical care.Mid-Surgery Injuries. When having surgery, there is a chance that parts of the body will be damaged. For example, a patient undergoing appendectomy surgery may sustain an unintentional injury to the intestine, which is attached to the appendix. This type of injury may be detected during the procedure and corrected immediately, or it may become a problem during recovery when medical staff notices it. Additional surgery may be required if the injury is severe enough.
How To Write a Procedure Note
The procedure note that is being written after the medical procedure should be clear and concise. With that being said, here are the steps that one should follow when writing the procedure note:
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1. Start With the General Information
The first step would be writing the basic elements of the procedure note first, which includes the date of the procedure, the exact time that the medical procedure was administered, the type of procedure that is to be performed on the patient, the doctor who performed the procedure and any overseeing physician, if applicable.
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2. Write the Secondary Elements of the Procedure Note
After writing the general information, you can then begin writing the elements that are considered to be important but don’t have the heaviest bearing on the procedure note. These elements are the indications for the medical procedure, the patient’s verbal or written consent letter, and the laboratory values or results that prove that the said procedure was performed on the patient in a Safe Manner.
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3. Write the Main Elements
After including the secondary elements, the main elements of the procedure note will be written. The main elements include the detailed process of the medical procedure that was performed on the patient (includes the preparation, administration of anesthesia, the Surgical Equipment used, and the procedural technique), and any major or minor complications that may have arisen during the procedure, including an estimated amount of blood that was lost from the patient.
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4. Write the Concluding Elements
Following the main elements of the procedural note would be the concluding elements. These include the patient disposition, the follow-up plan, and the name and license number of the doctor who performed the medical procedure along with his/her signature.
FAQs
What is a surgical suture?
A surgical suture is a medical device that is used to hold body tissues together following an injury or surgery.
In most cases, a needle with a length of thread attached is used for application. Suturing is typically performed by surgeons, physicians, dentists, podiatrists, eye doctors, registered nurses and other trained nursing personnel, medics, clinical pharmacists, and veterinarians. Sutures are secured with surgical knots.
What is a medical cast?
A cast immobilizes a broken bone (also known as a fracture) and prevents the area around it from moving as it heals.
Casts also help to prevent or reduce muscle contractions and keep the injured area immobile, which can help reduce pain, especially after surgery.
Does a procedure note have legal implications?
A procedure note can have legal implications should any issues arise since it has to be signed by the doctor who performed the medical intervention. By clearly and concisely recording relevant data about any medical procedures, doctors and hospitals can be protected by legal repercussions should there be a dispute or challenge filed in court.
Writing medical documentations such as procedure notes is a vital task, but can be an especially daunting task if junior medical practitioners are involved. But as long as the important elements are remembered, and the document is written clearly and concisely, problems can be avoided. Experience can also help in making the task of documenting a lot easier. In this article, examples of procedure notes are available and can be downloaded to be used as a personal reference should you need to write one.
