Procedure Note
A procedure note should be written in the chart after a procedure is performed (eg, lumbar puncture).
Procedure Note
Date and time: Procedure: Indications: Patient Consent: Document that the indications, risks and alternatives to the procedure were explained to the parents (and patient if applicable). Note that the parents and the patient were given the opportunity to ask questions and that the parents consented to the procedure in writing. Lab tests: Relevant labs, such as the CBC Anesthesia: Local with 2% lidocaine Description of Procedure: Briefly describe the procedure, including sterile prep, anesthesia method, patient position, devices used, anatomic location of procedure, and outcome. Complications and Estimated Blood Loss (EBL): Disposition: Describe how the patient tolerated the procedure. Specimens: Describe any specimens obtained and labs tests which were ordered.
A procedure note should be written in the chart after a procedure is performed (eg, lumbar puncture).
Procedure Note
Date and time: Procedure: Indications: Patient Consent: Document that the indications, risks and alternatives to the procedure were explained to the parents (and patient if applicable). Note that the parents and the patient were given the opportunity to ask questions and that the parents consented to the procedure in writing. Lab tests: Relevant labs, such as the CBC Anesthesia: Local with 2% lidocaine Description of Procedure: Briefly describe the procedure, including sterile prep, anesthesia method, patient position, devices used, anatomic location of procedure, and outcome. Complications and Estimated Blood Loss (EBL): Disposition: Describe how the patient tolerated the procedure. Specimens: Describe any specimens obtained and labs tests which were ordered.
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