Bronchoscopy Note Template
: 1A: The Bronchoscopy Report. This presentation is part of a comprehensive curriculum for Flexible Bronchoscopy. Bronchoscopy note template. Scholarly Search Engine Find information about academic papers by weblogr.com. Bronchoscopy note template. Name Stars Updated.
Central Venous Catheter (CVC, Central Line) Placement Date: Time: Indication: Hemodynamic monitoring/Intravenous access Resident: Attending: A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a dependent position appropriate for central line placement based on the vein to be cannulated. The patient’s was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the surrounding skin area. A triple lumen Cordis catheter was introduced into the the using the Seldinger technique. The catheter was threaded smoothly over the guide wire and appropriate blood return was obtained.
Each lumen of the catheter was evacuated of air and flushed with sterile saline. The catheter was then sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate. Was present for the entire procedure. Estimated Blood Loss: The patient tolerated the procedure well and there were no complications. Other procedure note examples:.
Sigmoidoscopy
Also, thank you to my two favorite websites for helping me write notes in the hospital:. Lumbar Puncture Date: Time: Indication: Altered Mental Status Resident: Attending: A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in the lateral decubitus position in a semi-fetal position with help from the nursing staff. The area was cleansed and draped in usual sterile fashion. 1% lidocaine was used anesthetize the surrounding skin area.
Colposcopy
A spinal needle was placed in the interspace. Clear cerebral spinal fluid was obtained and the opening pressure was noted to be. 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. Was present for the entire procedure Estimated Blood Loss: The patient tolerated the procedure well and there were no complications.
Other procedure note examples:. Also, thank you to my two favorite websites for helping me write notes in the hospital:.
Thoracentesis Date: Time: Indication: Large pleural effusion Resident: Attending: A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient’s side was prepped and draped in a sterile manner after the appropriate infiltration level was confirmed by ultrasound.
1% lidocaine was used anesthetize the surrounding skin. A finder needle was then used to locate fluid and 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 of clear yellow fluid removed. Was present for the entire procedure.
A post-procedure chest x-ray was ordered and the fluid will be sent for several studies. Estimated Blood Loss: The patient tolerated the procedure well and there were no complications. Other procedure note examples:. Also, thank you to my two favorite websites for helping me write notes in the hospital:. Swan-Ganz Catheter Placement Date: Time: Indication: Hemodynamic monitoring/Intravenous access Resident: Attending: A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a dependent position appropriate for central line placement based on the vein already cannulated with a 9F Cordis catheter.
Endoscopy
The patient’s was prepped and draped in sterile fashion. A triple lumen continuous cardiac output Swan-Ganz catheter was brought onto the field and each line flushed with sterile saline and the SVO2 sensor calibrated. The catheter was introduced into the Cordis catheter to a distance of 15-17 cm. The balloon was then inflated and the catheter was advanced through the right ventricle and into the pulmonary artery until a wedge position pressure tracing was obtained. The balloon was then deflated and verification of return of a pulmonary artery pressure tracing made.
During the floating procedure to position the catheter the position of the catheter tip was determined by continuous pressure monitoring via the distal port. The catheter was locked to the Cordis with the tip inserted to a distance of and a sterile dressing applied. Was present for the entire procedure. Estimated Blood Loss: The patient tolerated the procedure well and there were no complications.
Other procedure note examples:. Also, thank you to my two favorite websites for helping me write notes in the hospital:. Endotracheal Intubation Date: Time: Indication: Respiratory Distress Resident: Attending: A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a flat position.
Sedation was obtained using, and additionally with. The patient was easily ventilated using an ambu bag. The was used and inserted into the oropharynx at which time there was a Grade 1 view of the vocal cords. 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 23 cm, measured at the teeth. Was present for the entire procedure. A chest x-ray was ordered to assess for pneumothorax and verify endotrachealtube placement. Estimated Blood Loss: The patient tolerated the procedure well and there were no complications. Other procedure note examples:.
Also, thank you to my two favorite websites for helping me write notes in the hospital:. THORACOSTOMY (CHEST TUBE) PLACEMENT Date: Time: Indication: Pneumothorax/Hemothorax Resident: Attending: A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable.
The patient was positioned appropriately for chest tube placement. The patient’s chest was prepped and draped in sterile fashion.
1% Lidocaine was used to anesthetize the surrounding skin area. A skin incision was made in the mid-axillary line at the inframammarycrease. Utilizing blunt dissection a subcutaneous tunnel was created cephalad just adjacent to the superior rib. The pleural space was entered bluntly and gush of was observed. A finger was inserted into the pleural space to check for anatomy and guide tube insertion. A thoracostomy tube was inserted using a Kelly clamp and positioned appropriately.
The chest tube was sutured securely to the skin and a sterile dressing applied. A pleurevac was attached to the chest tube and a chest x-ray obtained.
Was present for the entire procedure. Estimated Blood Loss: The patient tolerated the procedure well and there were no complications. Other procedure note examples:.
Also, thank you to my two favorite websites for helping me write notes in the hospital:. ARTERIAL LINE (A-Line) PLACEMENT Date: Time: Indication: Hemodynamic monitoring Resident: Attending: A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. Allen’s test was performed to ensure adequate perfusion. The patient’s wrist was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the area. A Arrow arterial line was introduced into the artery. The catheter was threaded over the guide wire and the needle was removed with appropriate pulsatile blood return. The catheter was then sutured in place to the skin and a sterile dressing applied.
Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate. Was present for the entire procedure. Estimated Blood Loss: The patient tolerated the procedure well and there were no complications. Other procedure note examples:. Also, thank you to my two favorite websites for helping me write notes in the hospital:.