A procedure note should be written in the chart when a procedure is performed. Procedure notes are brief operative notes.
Date and time:
Patient Consent: Document that the indications and risks were explained to the patient and that the patient consented: "The patient understands the risks of the procedure and consents in writing." Lab tests: Relevant labs, such as the INR and 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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