Procedure Note

PROCEDURE: The official name of the procedure, not an abbreviation of it. Central venous catheter, not "central line" or "TLC".

CONSENT: Procedure, benefits, risks (include those of bleeding, infection, injury, pneumothorax, stroke, death, and anesthesia), and alternatives explained to the patient who voiced understanding of the information and agreed to proceed with the (spinal tap, thoracentesis, paracentesis, central venous catheter placement, etc.) Consent signed and on chart (if so).

INDICATION: meningitis, pleural effusion, ascites, etc.

PHYSICIAN(S): The name of the attending and all residents in a list.

DESCRIPTION: Area prepped and draped in a sterile fashion. (Local, spinal, etc.) anesthetic administered with (cc medication). Describe technique including instruments, body location, occurrences, etc.

COMPLICATIONS: Pneumothorax, etc

ESTIMATED BLOOD LOSS: amount in mL.

DISPOSITION: Pt. alert, oriented, and resting; breathing nonlabored; extremities neurovascularly intact; incision clean, dry and intact; etc.