PROCEDURE 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]