Procedure note template
The note for any procedure without a template of its own: endoscopy, cystoscopy, bronchoscopy, pleural aspiration, lumbar puncture, skin excision, nerve block.
- Indication
- One line.
- Pre-procedure
- Bloods, consent, fasting, anticoagulation held.
- Procedure
- Steps, devices, contrast or radiation where they apply.
- Findings
- Seen or measured.
- Complications
- Nil, or the complication and its management.
- Post-procedure
- Recovery, observation period, disposition.
- Plan
- Medications, follow-up, results to chase.
Worked examples
Procedure note · pleural aspiration Rossi, Mario · 76M · Synthetic patient
Indication Symptomatic right pleural effusion on chest radiograph. Pre-procedure Written consent obtained. INR 1.1, platelets 240. No anticoagulation. Sitting position, ultrasound marked. Procedure US-guided R pleural aspiration, 7th ICS, posterior axillary line, lidocaine 1% 10 mL. 900 mL straw-coloured fluid drained. Findings Free-flowing effusion with no septation. Fluid sent for pH, protein, LDH, glucose, cell count, MCS and cytology; serum protein and LDH sent. Complications None. No pneumothorax on post-procedure imaging. Post-procedure Observed 2 h on the ward. SpO2 stable on RA. Breathing subjectively easier. Plan Review fluid results. Respiratory clinic in 2 weeks. Repeat CXR if breathlessness recurs.
Procedure note · lumbar puncture Hall, Megan · 38F · Synthetic patient
Indication Suspected SAH. CT brain normal; LP more than 12 h after headache onset. Pre-procedure Written consent obtained. Platelets 210, INR 1.0. CT reviewed and reported as showing no space-occupying lesion. Procedure LP at L3/4, left lateral position, 22G atraumatic needle, first pass. Opening pressure 16 cmH2O. Findings 4 tubes, 2 mL each, clear and colourless. RBC count falling across tubes 1 to 4. Sent for xanthochromia (spectrophotometry), cell count, protein, glucose and culture. Complications None. No radicular pain during the procedure. Post-procedure Observed 1 h. No headache on sitting. Mobilised without difficulty. Plan Chase spectrophotometry, neurology review if positive, advise about post-puncture headache before discharge.
