A procedure note records a procedure done at the bedside or in a clinic room: why it was done, the consent and time-out, each step, what came out, and how the patient did. Copy the free template, see an ultrasound-guided paracentesis on the ward and an abscess incision and drainage in clinic, and check what goes in each part.
Blank procedure note template
FreePROCEDURE NOTE Patient: [Name, date of birth, record number] Date and time: [Date, start and end times] Location: [Ward and bed, emergency department, clinic procedure room, or other] Procedure: [Name of the procedure, side and site, diagnostic or therapeutic, and any imaging guidance] Operator: [Name, credentials] Assistant: [Name and role, or none] Supervisor: [Name, and whether present for the whole procedure or for named steps, when a trainee performed it; or not applicable] INDICATION AND SAFETY CHECKS Indication: [The diagnosis or problem, and the findings that make the procedure worthwhile now] Bleeding risk: [Platelets, INR, or other results that matter, with dates, and whether anything was corrected and why; or not needed] Blood thinners: [Anticoagulant or antiplatelet, last dose, held or continued; or none] Allergies: [Local anesthetic, latex, chlorhexidine, iodine, or dressing adhesive, with the reaction; or none known] CONSENT AND TIME-OUT Consent: [Written or verbal, who gave it, capacity, interpreter if used; the risks, benefits, and alternatives discussed] Time-out: [Time, who took part, and that patient, procedure, side and site, and equipment were confirmed] PREPARATION AND ANESTHESIA Position: [How the patient was positioned, and why] Site selection: [Landmarks, or ultrasound findings at the chosen site; site marked or not] Sterile prep: [Skin antiseptic and drying time, drape, and barrier precautions such as cap, mask, gown, and sterile gloves] Anesthesia: [Local anesthetic with strength, volume, and where it went; sedation, if any, with who gave and monitored it; or none] TECHNIQUE Equipment: [Needle, catheter, blade, or kit, with type and size] Steps: [Each step in order: approach, number of passes or attempts, what came back and at what depth, and how position or flow was confirmed] Finish: [Catheter or needle removed or secured, closure, packing, and dressing] FINDINGS AND SPECIMENS Findings: [What was found: fluid color, clarity, and volume; pus; tissue; or a pressure reading] Specimens: [Each specimen, the tests requested, and where it went; or none] Estimated blood loss: [Volume in mL] OUTCOME Complications: [None, or what happened, when, and what was done] Tolerance: [Pain score, and vital signs before and after] Medications given: [Drug, dose, route, and time, such as albumin or an antibiotic; or none] Post-procedure checks: [Imaging, labs, or observation ordered, such as a chest X-ray after a central line; or none needed] AFTERCARE AND FOLLOW-UP Instructions: [Site care, activity, pain relief, and the signs that mean come back sooner; given verbally, in writing, or both] Results: [Who reviews pending results, and how the patient will hear them] Follow-up: [When, where, and with whom] Signed: [Operator name, credentials, date and time; cosignature if your organization requires one]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Medical ward, at the bedside, resident with supervising physician
Thomas Reyes, born March 14, 1968, male. Record number 5531208. November 9, 2026, 10:20 to 11:35. Medical ward, room 612, at the bedside. Ultrasound-guided large-volume paracentesis, left lower quadrant, diagnostic and therapeutic. Operator: Dr. Priya Raman, internal medicine resident, second year. Supervisor: Dr. Mark Feldman, internal medicine, present for the whole procedure. Assistant: Jamie Cole, RN, who took vital signs and changed the drainage bottles.
58-year-old man with alcohol-related cirrhosis, no alcohol for 8 months, admitted 2 days ago with tense ascites: a tight, swollen abdomen, early fullness, and breathlessness lying flat, on spironolactone 100 mg and furosemide 40 mg daily. Last paracentesis 5 weeks ago, 5.5 L. A diagnostic sample was also needed on admission, to rule out spontaneous bacterial peritonitis. Platelets 68 × 10⁹/L and INR 1.7 this morning; no platelets or plasma given, as routine correction isn’t recommended before paracentesis. Creatinine 88 µmol/L (1.0 mg/dL); serum albumin 28 g/L (2.8 g/dL). Blood thinners: none. Allergies: none known.
Risks discussed: bleeding into the abdominal wall or abdomen, infection, bowel puncture, fluid leaking from the site, and low blood pressure after a large volume is removed. Benefits: easier breathing and comfort, and a sample to check for infection. Alternative: diuretics alone, which hadn’t controlled the fluid. He has capacity and signed written consent at 10:05. Time-out at 10:18 with Dr. Feldman and the nurse: patient, procedure, left lower quadrant site, and albumin on the ward confirmed.
Supine, head of the bed at 30 degrees, tilted slightly to the left. Ultrasound: large free fluid, deepest pocket 6 cm in the left lower quadrant, no bowel against the wall at the site; color Doppler showed no vessels in the needle path. Site 4 cm above and 4 cm medial to the left anterior superior iliac spine, lateral to the rectus sheath, marked. Chlorhexidine-alcohol, dried for 2 minutes; sterile drape; cap, mask, and sterile gloves; probe in a sterile cover. Lidocaine 1%, 10 mL, from skin to peritoneum; fluid drawn back at 4 cm.
8 French catheter-over-needle paracentesis kit. Z-track entry: skin pulled 2 cm down before the needle went in. Needle advanced with gentle suction; clear fluid at 4.5 cm on the first pass. Catheter slid over the needle and the needle withdrawn. 60 mL drawn by syringe for studies, then the catheter connected to vacuum bottles. Drainage stopped at 6.2 L, when flow slowed and didn’t pick up with a small turn to the left. Catheter removed, pressure held for 2 minutes, and a small occlusive dressing applied.
Clear, straw-colored fluid, not bloody or cloudy. Volume removed: 6.2 L over 70 minutes. Specimens: cell count and differential, albumin, and total protein in labeled tubes; Gram stain; culture, with 10 mL into each of an aerobic and an anaerobic blood culture bottle at the bedside. All to the lab at 10:45. Estimated blood loss: under 5 mL.
Complications: none; no leak at the site at 30 minutes. Tolerance: comfortable throughout, abdomen soft, breathing easier lying flat. BP 112/70 and HR 86 before; 108/66 and 90 at the end; 110/68 and 84 at 1 hour. Medications given: albumin 25%, 50 g IV over 1 hour from 11:40, about 8 g per liter removed, because more than 5 L were drained. Post-procedure checks: vital signs only.
Vital signs every 15 minutes for 1 hour, then every 4 hours. Lie on the right side for 2 hours to limit leaking. Check the dressing each shift; if it leaks, put an ostomy bag over the site and page the team. Continue spironolactone 100 mg and furosemide 40 mg daily, with a 2 g sodium diet. Creatinine and sodium tomorrow morning. Dr. Raman will review the fluid results today and tell Mr. Reyes. Hepatology clinic in 3 weeks.
Added at 16:30 by Dr. Raman. Ascitic white cells 210 per mm³ with 18% neutrophils, so 38 neutrophils per mm³, under 250: no spontaneous bacterial peritonitis. Ascitic albumin 9 g/L (0.9 g/dL); serum-ascites albumin gradient 19 g/L (1.9 g/dL), above 11 g/L (1.1 g/dL), which fits portal hypertension. Total protein 16 g/L (1.6 g/dL). Gram stain: no organisms. Culture pending; no antibiotics started. Mr. Reyes told at 16:45.
Written by Priya Raman, MD, internal medicine resident, November 9, 2026, at 11:55. Cosigned by Mark Feldman, MD, internal medicine, at 13:20.
Family practice clinic, procedure room, local anesthetic
Jordan Ellis, born July 2, 1997, male. Record number 2290417. November 10, 2026, 15:10 to 15:35. Family practice clinic, procedure room. Incision and drainage of a skin abscess, right lateral thigh, with packing. Operator: Dr. Nadia Haddad, family physician. Assistant: Chris Moreno, clinic nurse, who set up the tray and labeled the swab.
29-year-old landscaper with 5 days of a painful, growing lump on the outer right thigh. No fever. Second abscess this year: the first, on the left thigh in July, was drained at a walk-in clinic and not cultured. No diabetes; no injection drug use. T 37.0 °C (98.6 °F), HR 76. Tender, fluctuant swelling, 4 × 3 cm, with a yellow center pointing; redness 1 cm beyond its edge; no streaking, no crepitus; groin nodes not enlarged. Skin abscess, right thigh; culture because this is a recurrence. Bleeding results: not needed. Blood thinners: none. Allergies: none known; has had lidocaine before.
Verbal consent, per clinic policy. Risks discussed: pain with the injection, bleeding, a scar, incomplete drainage that may need a second procedure, and the abscess coming back. Alternative: warm compresses alone, unlikely to work at this size. He agreed. Time-out at 15:08 with the nurse: patient, procedure, and right lateral thigh confirmed.
Lying on his left side. Most fluctuant point marked. Skin cleaned with chlorhexidine; sterile gloves and instruments; fenestrated drape. Lidocaine 1% with epinephrine, 6 mL, as a field block around the abscess and along the incision line, not into the cavity.
No. 11 blade. 2 cm linear incision over the most fluctuant point, along the skin lines. Pus came out under pressure. Swab taken from deep in the cavity before irrigation. Curved hemostat swept around the cavity to break up pockets; cavity about 3 cm deep. Irrigated with sterile saline by syringe until the return was clear. Packed loosely with 1 cm plain ribbon gauze, about 20 cm, with a 2 cm tail left out. Gauze and tape over the top.
About 8 mL of thick yellow pus, no foul smell. Loculated cavity, 3 cm deep; no foreign body; no tracking beyond the swelling. Specimens: swab of pus for culture and sensitivity, to the community lab. Estimated blood loss: about 5 mL.
Complications: none. Tolerance: pain 7 out of 10 during the injection, 2 out of 10 at the end; walked out normally. Medications given: none. Antibiotics discussed: the abscess is fully drained, with little redness and no fever, so the extra benefit is small; he chose to wait for the culture. Edge of the redness outlined in pen.
Keep the dressing on for 24 hours, then shower and change the outer gauze daily; leave the packing in. Ibuprofen 400 mg every 6 to 8 hours with food, or acetaminophen, for pain. Back to work tomorrow with the wound covered. Come back sooner for redness spreading past the pen line, fever, red streaks up the leg, or pain getting worse. Written wound care sheet given. Nurse visit on November 12 to remove the packing and check the wound. Dr. Haddad will review the culture and call him; if it grows MRSA or another abscess appears, they’ll discuss ways to prevent a recurrence.
Signed by Nadia Haddad, MD, family physician, November 10, 2026, at 15:50.
Who had what done, where, and by whom. Name the procedure as it was done, with the side, the site, and any imaging guidance.
Avoid: “Paracentesis performed.” Write “ultrasound-guided paracentesis, left lower quadrant, diagnostic and therapeutic,” so the next reader knows the site and the reason at a glance.
Why this procedure, for this patient, today, and what you checked before you started.
Avoid: Leaving out a low platelet count or a raised INR because you went ahead anyway. Record the number and your reason, such as guidance that correction isn’t needed for this procedure.
What the patient agreed to, and the pause before you started that confirmed the right patient, procedure, and site.
Avoid: “Consent obtained.” Name the risks you discussed. For a paracentesis that means bleeding, infection, bowel puncture, a leak at the site, and low blood pressure after a large volume.
How you set up: position, site, sterile technique, and the anesthetic. These lines answer most later questions about infection or a wrong site.
Avoid: “Sterile technique” for everything. Say what you used: full barrier precautions for a central line, or sterile gloves and instruments for an abscess drainage.
What you did, step by step, for this patient. Another clinician should be able to tell what went where, and how you knew it was in the right place.
Avoid: Pasting the kit’s standard steps. If you needed a second pass, or stopped early because flow slowed, say so.
What you found and what you sent. The lab, the ward team, and the next clinician look here first.
Avoid: “Fluid sent to the lab.” List each test. A culture nobody asked for can’t be followed up.
How the procedure ended for the patient, and what you gave or checked afterward.
Avoid: “Tolerated well” on its own. Add the numbers: blood pressure before and after, and the pain score at the end.
What the patient or the ward does next, who chases the results, and when you see the patient again.
Avoid: A culture with no owner. Name who reviews it and how the patient will hear the result.
Standard text that says “one pass, no complications” after three attempts is a false record. Read each line against what happened, and delete what didn’t.
Volume drained, depth reached, attempts made, packing length, and blood loss all matter at the next procedure. “Large volume” and “minimal” tell the next clinician nothing.
Name every test you sent: cell count, albumin, culture, cytology. If the lab only gets a tube and a vague request, a result can go missing, and nobody notices.
Albumin after a large paracentesis, an antibiotic, or a tetanus booster after a wound repair belongs in the note with dose and time, as well as on the medication record.
If you stopped, moved site, or handed over to someone else, write it: what you tried, how many attempts, why you stopped, and what happens next. A failed attempt is still a procedure.
Write the note before you move on to the next patient. Add fluid results or cultures later as a dated addendum, so the record shows what you knew and when.
Vero Scribe writes the procedure note in your template from your dictation, or from the conversation in the room with the patient’s consent. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Write it right after the procedure, before you see the next patient. Start with the procedure, site, and team, then the indication and any bleeding checks. Record the consent and time-out, then the preparation, anesthetic, and each step as it happened. Finish with findings, specimens, blood loss, complications, how the patient tolerated it, and the aftercare and follow-up. Add results that come back later as a dated addendum.
The procedure and site, date and time, the operator and any assistant or supervisor, the indication, consent, time-out, anesthesia, sterile prep, technique, findings, specimens, estimated blood loss, complications, the patient’s tolerance, post-procedure instructions, and follow-up. Check your organization’s policy for anything else it requires.
A procedure note covers a procedure at the bedside, in the emergency department, or in a clinic room, usually under local anesthetic, by one operator with perhaps one assistant. An operative note records an operation in the operating room, with an anesthesia team, diagnoses before and after, counts, and often implants. The procedure note is shorter, but keeps the same core: indication, consent, time-out, technique, findings, complications, and the plan.
Any procedure done outside the operating room: paracentesis, thoracentesis, lumbar puncture, central and arterial lines, chest tubes, joint aspiration and injection, abscess drainage, laceration repair, skin biopsy, and nail procedures, among others. Bigger procedures in a procedure suite, such as a colonoscopy, often have a report of their own.
The indication, platelets and INR with whether anything was corrected, consent, time-out, the ultrasound findings at the site, the anesthetic, the needle or catheter size, the fluid’s appearance and volume, and the studies sent, such as cell count and differential, albumin, total protein, and culture in blood culture bottles. After a large-volume paracentesis of more than 5 L, record the albumin given, usually 6 to 8 g per liter removed, and the blood pressure before and after.
Write a procedure note anyway. Record what you tried, where, how many attempts, why you stopped, any complication, and what happens next, such as a second operator, imaging-guided drainage, or a referral. The next clinician needs to know what was already tried.
Yes. Copy it, or download it as a Word or text file. No account needed.
Yes. Vero Scribe writes the note in your template from your dictation after the procedure, or from the conversation in the room with the patient’s consent. You review and edit each section before it goes into the record.
The SOAP note reordered: assessment and plan on top, with the history and findings below to back them.
For clinical phone calls and nurse triage: the caller, red flags, advice, disposition, and who calls back.
The chart note for a refill or renewal between visits: last fill, monitoring due, safety checks, the decision, and who approved it.
Your chart note on a lab or imaging result: the value and trend, urgency, action, patient contact, and tracking.
The record of a team or family care conference: attendance, consent, each discipline’s update, decisions, and actions with owners and dates.
How Vero Scribe turns your dictation into a structured procedure note, with laceration repair, skin biopsy, and joint injection examples.
For operations in the operating room, with a laparoscopic cholecystectomy and an umbilical hernia repair.
The written aftercare a patient takes home, with warning signs and appointments.
How Vero handles notes on a busy emergency shift, procedures included.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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