Procedure Notes

[vtach]

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Does anyone know of a good website, or a website that has examples of procedure notes?

 

[doepug]

No... but procedure notes aren't that hard. Bedside procedures typically just need a short paragraph in the chart, in this kind of format:

Indication: - describe why you did the procedure
Consent: - document that a form was signed and that risks and benefits were explained
Procedure: - describe what you did, using "sterile" and "without complications" liberally
Specimen: - if applicable, describe what you sent

...and if you're a student, make sure to document that Dr. X "was present throughout the procedure." Don't forget to sign your name at the bottom.

Cheers,
doepug (MS IV)

 

[vtach]

OK I guess I should have been a little more specific, I know what to include in a note, but sometimes it is nice to see examples of procedure notes, to see what others include. Any Maxwells has the basic outlines of most notes that need to be written. I just wanted to find examples to look through.

 

[womansurg]

The Intern Manual (I think it's called - the little red paperback) has examples of dictations for appendectomies, I think line placements...so forth

I used to get copies from other staff/residents when I started out (what the hell is important to say on this lap chole???). That worked well.

 

[Winged Scapula]

I did (still do) the same thing as womansurg, especially for operative dictations - since ours are on-line, I just printed out "samples" of the most common procedures/operations so when the time came I'd know what the write/say.

The little red pocketbook she mentions is the "The Surgical Intern Survival Pocket Handbook" - pretty handy to have and cheap.