Documentation template for clinical and surgical procedures.
Procedure notes provide a contemporaneous record of a clinical procedure, including consent, technique, findings and post-procedure instructions. They are medico-legally important.
PROCEDURE NOTE ===================================== DATE: ___________ TIME: ___________ OPERATOR: _____________________________ ASSISTANT: ____________________________ LOCATION: _____________________________ PATIENT: ______________________________ DOB: _____________ NHS No: ____________ PROCEDURE: ____________________________ INDICATION: ___________________________ CONSENT: Written / Verbal / Emergency Risks discussed: Yes / No ANAESTHESIA / ANALGESIA: Type: _________________________________ Drug / Dose: __________________________ PATIENT POSITION: _____________________ TECHNIQUE: [Step by step description of procedure] FINDINGS: [What was found during the procedure] SPECIMENS: Specimen 1: ___________________________ sent to: ___ Specimen 2: ___________________________ sent to: ___ COMPLICATIONS: None / [describe] ESTIMATED BLOOD LOSS: _________________ POST-PROCEDURE STATUS: [Patient condition immediately post procedure] INSTRUCTIONS: 1. 2. FOLLOW-UP: ____________________________ SIGNATURE: ____________ DATE: _________ NAME (print): __________________________ GMC/NMC No: ___________________________