Procedure Note Templates:
  Thoracentesis
  Intubation
  PICC
  Subclavian CVC
  Internal Jugular CVC
  Internal Jugular CVC, U/S Guided
  Femoral CVC
  Paracentesis
  Lumbar Puncture
  Femoral A-line
  Radial A-line
  Pulmonary Artery Catheter
  Transvenous Pacemaker
  Bone Marrow Biopsy

PROCEDURE:
Thoracentesis, U/S guided.

INDICATION:
Large pleural effusion.

PROCEDURE OPERATOR:

CONSENT:
Consent was obtained from the patient prior to the procedure. Indications, risks, and benefits were explained at length.

PROCEDURE SUMMARY:
A time out was performed. The patient was prepped and draped in a sterile manner using chlorhexidine scrub after the appropriate level was percussed and confirmed by ultrasound. U/S images were permanently documented. 1% lidocaine was used to numb the region. A finder needle was then used to attempt to locate fluid; however, a 22-gauge, 3 1/2-inch spinal needle was required to actually locate fluid. Fluid was aspirated on the second attempt only after completely hubbing the spinal needle. Clear yellow fluid was obtained. A 10-blade scalpel used to make the incision. The thoracentesis catheter was then threaded without difficulty. The patient had 1200 mL of clear yellow fluid removed. No immediate complications were noted during the procedure. Dr. _____ was present during the entire procedure. A post-procedure chest x-ray is pending at the time of this dictation. The fluid will be sent for several studies.

ESTIMATED BLOOD LOSS:
PROCEDURE:
Endotracheal intubation.

INDICATIONS:
Respiratory distress.

PROCEDURE OPERATOR:

PROCEDURE SUMMARY:
Permit was implied secondary to emergent situation. A MAC 3 blade was inserted into the oropharynx at which time the vocal cords were visualized. A 7.5-French endotracheal tube was inserted and visualized going through the vocal cords. The stylette was removed. Colorimetric change was visualized on the CO2 meter. Breath sounds were heard in both lung fields equally. The endotracheal tube was placed at 22 cm, measured at the teeth.

COMPLICATIONS:

ESTIMATED BLOOD LOSS:
PROCEDURE:
Non-tunneled peripherally inserted central catheter (PICC), U/S guided.

INDICATION:
Need for long-term IV antibiotics.

PROCEDURE OPERATOR:

CONSENT:

PROCEDURE SUMMARY:
A Time-Out was performed. The patient was then prepped and draped in standard sterile fashion using chlorhexidine scrub. Local anesthesia was achieved with 1% lidocaine. The <LEFT/RIGHT> <BASILIC/BRACHIAL/CEPHALIC> vein was accessed under ultrasound guidance using a micropuncture needle. Ultrasound images were permanently documented. The needle was then exchanged for a 5-French coaxial dilator over a wire. A <SINGLE/DOUBLE> lumen <5/6> french PICC line catheter was trimmed to <___> cm and inserted through peel-away sheath. The peel-away sheath was then removed, and the catheter was secured to the skin with silk suture. At time of procedure completion, the catheter flushed and aspirated easily. The patient tolerated the procedure well without any immediate complication. Postprocedure x-ray shows the tip of the catheter at the cavoatrial junction.

ESTIMATED BLOOD LOSS:
PROCEDURE:
Subclavian central venous catheter.

INDICATION:

PROCEDURE OPERATOR:

CONSENT:
Consent was obtained from the patient prior to the procedure. Indications, risks, and benefits were explained at length.

PROCEDURE SUMMARY:
A time out was performed. The patient was placed in Trendelenburg position. <LEFT/RIGHT> chest region was prepped and draped in sterile fashion using chlorhexidine scrub. Anesthesia was achieved with 1% lidocaine. The introducer needle was inserted approximately two centimeters lateral to the normal curvature of the patient's <LEFT/RIGHT> clavicle. Venous blood was withdrawn. Syringe was removed and a guidewire was advanced into the introducer needle. A small incision was made at the skin surface with a scalpel and the introducer needle was exchanged for a dilator over the guidewire. After appropriate dilation was obtained, the dilator was exchanged over the wire for an 8.5 French, quad-lumen, central venous catheter. The wire was removed and the catheter was sutured in place at <__> cm. The patient tolerated the procedure without any hemodynamic compromise. At time of procedure completion, all ports aspirated and flushed properly. Post-procedure x-ray shows the tip of the catheter within the SVC. Dr. ____ was present during all pertinent portions of the procedure.

ESTIMATED BLOOD LOSS:
PROCEDURE:
Internal jugular central venous catheter.

INDICATION:

PROCEDURE OPERATOR:

CONSENT:

PROCEDURE SUMMARY:
A time-out was performed. The patient's <LEFT/RIGHT> neck region was prepped and draped in sterile fashion. Anesthesia was achieved with 1% lidocaine. The finder needle was inserted into the <LEFT/RIGHT> neck at the location of the apex of the triangle formed between the anterior and posterior bellies of the sternocleidomastoid muscle, and venous blood was withdrawn. The introducer needle was then inserted just adjacent to finder needle and venous blood was withdrawn into the syringe. The syringe was removed and the guidewire was advanced through the introducer needle. A small incision was made with a scalpel and the introducer needle was removed. A dilator was advanced over the guidewire until appropriate dilation was obtained. The dilator was removed and an 8.5 French central venous quad-lumen catheter was advanced over the guidewire and secured into place with 4 sutures at <__> cm. At time of procedure completion, all ports aspirated and flushed properly. Post-procedure x-ray shows the tip of the catheter overlying the SVC.

COMPLICATIONS:
There was some ventricular ectopic activity noted during the course of the procedure, which resolved within a few seconds after the guidewire was withdrawn.

ESTIMATED BLOOD LOSS:
PROCEDURE:
Internal jugular central venous catheter, U/S guided.

INDICATION:

PROCEDURE OPERATOR:

CONSENT:

PROCEDURE SUMMARY:
A time-out was performed. The patient's <LEFT/RIGHT> neck region was prepped and draped in sterile fashion using chlorhexidine scrub. Anesthesia was achieved with 1% lidocaine. The <LEFT/RIGHT> internal jugular vein was accessed under ultrasound guidance using a finder needle and sheath. U/S images were permanently documented. Venous blood was withdrawn and the sheath was advanced into the vein and the needle was withdrawn. A guidewire was advanced through the sheath. A small incision was made with a 10 blade scalpel and the sheath was exchanged for a dilator over the guidewire until appropriate dilation was obtained. The dilator was removed and an 8.5 French central venous quad-lumen catheter was advanced over the guidewire and secured into place with 4 sutures at <__> cm. At time of procedure completion, all ports aspirated and flushed properly. Post-procedure x-ray shows the tip of the catheter within the superior vena cava.

COMPLICATIONS:

ESTIMATED BLOOD LOSS:
PROCEDURE:
Femoral central venous catheter

INDICATION:
Need for intravenous access due to septic shock

PROCEDURE OPERATOR:

CONSENT:
Consent was implied due to the emergent nature of the procedure.

PROCEDURE SUMMARY:
The patient was prepped and draped in the usual sterile manner using chlorhexidine scrub. 1% lidocaine was used to numb the region. The finder needle was used to locate the <LEFT/RIGHT> femoral vein. A quad-lumen 8.5 French 20 cm catheter was inserted using the Seldinger technique. All ports aspirate and flushed without difficulty. The patient tolerated the procedure well without any immediate complications. The line was sutured into place and the area was cleaned and Tegaderm applied. Dr. ____ was present during the procedure.

ESTIMATED BLOOD LOSS:
PROCEDURE:
Diagnostic & Therapeutic Paracentesis, U/S guided.

INDICATION:
Worsening ascites.

PROCEDURE OPERATOR:

CONSENT:
Informed consent was obtained after risks and benefits were explained at length.

PROCEDURE SUMMARY:
A time-out was performed. The area of the <LEFT/RIGHT> abdomen was prepped and draped in a sterile fashion using chlorhexidine scrub. 1% lidocaine was used to numb the region. The skin was incised 1.5 mm using a 10 blade scalpel. The paracentesis catheter was inserted and advanced with negative pressure under ultrasound guidance. Ultrasound images were permanently documented. No blood was aspirated. Clear yellow fluid was retrieved and collected. Approximately 65 mL of ascitic fluid was collected and sent for laboratory analysis. The catheter was then connected to the vaccutainer and <__> liters of additional ascitic fluid were drained. The catheter was removed and no leaking was noted. 50 g of albumin was intravenously during the procedure. The patient tolerated the procedure well without any immediate complications. Dr. ____ was present during the procedure.

ESTIMATED BLOOD LOSS:
PROCEDURE:
Lumbar Puncture.

INDICATION:
Altered mental status and fever.

PROCEDURE OPERATOR:

CONSENT:

PROCEDURE SUMMARY:
A time-out was performed. The patient was placed in the <LEFT/RIGHT> lateral decubitus position in a semi-fetal position with help from the nursing staff. The area was cleansed and draped in usual sterile fashion. Anesthesia was achieved with 1% lidocaine. A 20-gauge 3.5-inch spinal needle was placed in the L4-L5 interspace. On the first attempt, clear cerebral spinal fluid was obtained. Four tubes were filled with 4 mL of CSF. These were sent for the usual tests, including 1 tube to be held for further analysis if needed. The patient had no immediate complications and tolerated the procedure well. Dr. ____ was present during the entire procedure.

ESTIMATED BLOOD LOSS:
PROCEDURE:
Femoral artery line placement. (A-line)

INDICATION:

PROCEDURE OPERATOR:

CONSENT:

PROCEDURE SUMMARY:
The patient was prepped and draped in the usual sterile manner using chlorhexidine scrub. 1% lidocaine was used to numb the region. The <LEFT/RIGHT> femoral artery was accessed using a needle. Pulsatile, arterial blood was visualized and the artery was then threaded using the Seldinger technique and a catheter was then sutured into place. Good wave-form was obtained. The patient tolerated the procedure well without any immediate complications. The area was cleaned and Tegaderm was applied. Dr. ____ was present during the entire procedure.

ESTIMATED BLOOD LOSS:
PROCEDURE:
Radial artery line placement. (A-line)

INDICATION:

PROCEDURE OPERATOR:

CONSENT:

PROCEDURE SUMMARY:
The patient was prepped and draped in the usual sterile manner using chlorhexidine scrub. 1% lidocaine was used to numb the region. The <LEFT/RIGHT> radial artery was palpated and successfully cannulated on the first pass. Pulsatile, arterial blood was visualized and the artery was then threaded using the Seldinger technique and a catheter was then sutured into place. Good wave-form was obtained. The patient tolerated the procedure well without any immediate complications. The area was cleaned and Tegaderm was applied. Dr. ____ was present during the entire procedure.

ESTIMATED BLOOD LOSS:
PROCEDURE:
Pulmonary Artery Catheter (Swan-Ganz)

INDICATION:
Shock, of unknown etiology.

PROCEDURE OPERATOR:

CONSENT:

PROCEDURE SUMMARY:
The patient was prepped and draped in the usual sterile manner. The Swan-Ganz catheter was tested. It was then inserted into the <LEFT/RIGHT> internal jugular central venous catheter. At approximately 15-cm the balloon was inflated and slowly advanced. Appropriate wave forms were obtained, both for right atrium, right ventricle, pulmonary artery and pulmonary wedge. Wave forms were all visualized. The patient had a PA pressure of <__>, pulmonary wedge pressure of <__>, central venous pressure of <__>, cardiac output <__> and SCR was <__>. From this data, it was determined that the patient was in <SEPTIC/CARDIOGENIC> shock.

COMPLICATIONS:

ESTIMATED BLOOD LOSS:
PROCEDURE:
Transvenous pacemaker.

INDICATION:
Bradycardia unresponsive to atropine.

PROCEDURE OPERATOR:

CONSENT:

PROCEDURE SUMMARY:
Using the previously placed <LEFT/RIGHT> internal jugular catheter, a bipolar pacing catheter was advanced into the Cordis. The catheter was advanced to approximately 15 centimeters whereupon the balloon was inflated. It was further advanced into the right atrium and then the right ventricle to a depth of <__> cm at which point pacing was achieved. The balloon was deflated and the catheter was retracted <__> cm. The pacer was then advanced an additional <__> cm and capture was reachieved at <__> mAmp. The patient tolerated the procedure well with no immediate complications. Dr. ____ was present during the entire procedure.

ESTIMATED BLOOD LOSS:
PROCEDURE:
Bone marrow aspirate and biopsy.

INDICATION:
Pancytopenia.

PROCEDURE OPERATOR:

CONSENT:
Consent was obtained from the patient. The risks and benefits were explained. The patient agreed to undergo the procedure. The consent form was signed and placed in the chart.

PROCEDURE SUMMARY:
The patient was laid in the <LEFT/RIGHT> lateral decubitus position. The <LEFT/RIGHT> posterior superior iliac spine was prepped and draped in a sterile fashion. The patient was premedicated with 10 mg of morphine sulfate IV and 1 mg of Ativan IV. The crest of the posterior superior iliac spine was located, and the skin as well as the surface of the bone was anesthetized with 1% lidocaine. A Kelly needle was introduced, and bone marrow aspirate was obtained without any difficulty. This was withdrawn, and the Jamshidi needle was advanced into the bone cavity. A bone marrow biopsy was obtained without any complications. Dr. ___ was present for the critical part of the procedure.

COMPLICATIONS:

ESTIMATED BLOOD LOSS:
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