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Template content
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Procedure Note Procedure - Name of procedure performed. Indication - Clinical indication and relevant pre-procedure findings. Consent / Timeout - Informed consent obtained (risks, benefits, alternatives discussed); patient questions answered. - Timeout / site verification performed when applicable. Document capacity/surrogate if relevant. Anesthesia / Analgesia - Local, topical, regional, sedation, or none—as used, with agents and approximate doses when known. Technique - Patient position, prep/drape, approach, instruments, and key steps. - Imaging or guidance used (ultrasound, fluoroscopy) if applicable. - Specimens obtained and disposition (pathology, culture). Findings - Intra-procedure findings relevant to diagnosis and next steps. Complications - None, or describe events and immediate management. Estimated Blood Loss - As applicable. Disposition / Aftercare - Immediate post-procedure condition, dressings/devices left in place, monitoring needs. - Patient instructions, activity restrictions, wound care, red-flag symptoms, and follow-up.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Captures consent, timeout, and technique elements reviewers look for.
- Keeps findings and specimens distinct from the narrative technique.
- Fits bedside procedures, clinic procedures, and minor interventions.
- Aftercare and contingency instructions land in a predictable place.
- 1Bedside procedures (I&D, laceration repair, lines, taps)
- 2Outpatient clinic procedures
- 3Minor interventions documented outside the OR
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Procedure Incision and drainage of left forearm abscess. Indication 3-day enlarging, fluctuant, tender abscess; failed outpatient warm compresses. Point-of-care ultrasound showed 2.5 cm collection. Consent / Timeout Risks (bleeding, infection, recurrence, scarring, nerve injury), benefits, and alternatives discussed; consent obtained. Timeout completed; site marked. Anesthesia 1% lidocaine with epinephrine, ~8 mL local infiltration. Technique Supine; chlorhexidine prep; sterile drape. #11 blade incision over fluctuance; ~4 mL purulent material expressed; loculations bluntly lysed; irrigated with sterile saline; iodoform packing placed; sterile dressing applied. Culture swab sent. Findings Purulent collection without surrounding crepitus or deep tracking on exam/US. Complications None. EBL minimal. Aftercare Packing change in 48 hours or sooner if saturated. Keep dressing clean/dry. Return for fever, spreading erythema, or severe pain. Empiric TMP-SMX discussed with primary clinician; wound check in clinic 48h.
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3. Review and sign
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