Everything that we are about to do in health care should be done through an informed consent. Every patient should know about the procedures that health care providers do to them so they can fully understand the benefits, risk, and the alternatives. Health care process would really require an extensive informed consent discussion especially a documentation of a specific procedure note. If we think that a certain intervention is essential, always make it clear to the patient why we should take that certain procedure. If they decline, it should also be stated to the medical record the reason why. In this article, you are going to know more about procedure note and its contents.

10+ Procedure Note Samples

1. Procedure Note Sample

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2. Neonatal Procedure Note

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3. Vasectomy Procedure Note

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4. Cardiac Procedure Note

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5. Procedure Note Format

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6. Chart Procedure Note

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7. Printable Procedure Note

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8. Penile Procedure Note

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9. Bronchoscopy Procedure Note

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10. Claim Procedure Note

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11. Parliamentary Procedure Note

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What is a Procedure Note?

A procedure note is considered as the largest section of the OP report wherein there will be a physical document of the specifics about what a physician did. The outline should be able to provide the details including patient position, approach, depth, anatomic site, findings. Physicians do not necessarily specify what approach they used. They can even document any type of complications as well as abnormal findings. They also document details like time of the procedure that requires more work. The physician can be able to include in the procedure note the biopsies, lesions, anastomoses, foreign bodies, grafts, blood loss, excisions, hardware used for repair, and tubes for feeding and other purposes. They can also provide report about the type of closure that has enough detail to give support to any additional work.

Example of Procedure Note

Vasectomy Procedure Note

PRE-OP DIAGNOSIS: Desires Elective Sterilization 
POST-OP DIAGNOSIS: Same 
PROCEDURE: Elective Bilateral Vasectomy 
Resident Physician: _ 
Supervising Physician: _
ANESTHESIA: (select one) _ Marcaine 0.5% or _Lidocaine 1% 
Total amount used: _ mL 
 
INDICATIONS: 
This gentleman desires elective sterilization. He was counseled regarding the risks, alternatives, and benefits of male sterilization by vasectomy. He was informed of the risks of the procedure, including but not limited to failure of the procedure to produce sterility, the risks of bleeding, infection, and injury to scrotal contents. All questions were answered in the pre-vasectomy conference and the required State of California consent form was signed. No guarantees were given or implied. A time out was taken prior to the procedure. 
 
PROCEDURE: 
The patient was laid supine on the procedure table. He was sterilely prepped and draped in the usual fashion. The vasa were identified bilaterally. The left vas was grasped using the three-finger technique. Local anesthesia with a 27 gauge needle was applied to the skin in the (select one) _ midline / _ lateral scrotum and to the left vas and surrounding tissue. A vas fixing forcep was used to grasp the vas through the scrotal skin. A vas dissecting instrument was then used to pierce the skin and down through the fascia. The vas was then identified and delivered through the incision. The surrounding vassal tissue was incised in the midline in a vertical fashion to reveal the vas. The vas was grasped with a vas forcep and delivered out of the fascia. The vas was distally and proximally grasped. 
 
(select one)
_ Method 1: The intervening segment of approximately 2 cm was excised and sent for pathologic review. The lumen of the vas were sealed with thermal fine wire cautery. The proximal vas was then closed over with fascia in a fascial interposition technique. 
_ Method 2: Small surgical clips were placed on the distal and proximal ends of the vas and. 
and the intervening segment of approximately 2 cm was excised. 
 
The right vas was attended to in the same fashion as the left vas after local anesthesia was applied to the vas and surrounding tissue. All bleeding was controlled. The scrotal fascia was (select one) _ allowed to close by primary intention / _ closed with 4-0 vicryl. Sterile dressings were applied and the patient was sent home with standard post-vasectomy instructions, including instructions to return with a semen sample for analysis after 15-20 ejaculations.

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FAQs

Does a procedure note requires patient consent?

Yes. It is noted that the patient was given an opportunity to ask questions and consent the procedure.

How should a procedure note be done?

It can be done either in written form or dictated.

What should be included in a procedure note?

It must have the date and time, name of the procedure done, indications, patient’s consent, type of anesthesia used, procedure description, disposition, signature, etc.

Procedure notes should be written or dictated clearly and concisely so that it would be easier to understand. It can also give clarifications to the patients if the texts are recorded correctly. Writing a procedure note should also be following a specific format so that it would be organized and more formal to read. Check out our sample procedure notes!

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