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. Rosetta Stone V3 2.11 Patch.
Other procedure note examples: • • • • • • • 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. 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: • •.
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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.