Ver el código de «Procedure sample documentation»

==Abscess drainage (Incision/Drainage)==
:Performed by:
:Authorized by:
:Consent: Verbal consent obtained.
:Risks and benefits: Risks, benefits, and alternatives were discussed
:Consent given by: Patient
:Patient understanding: patient states understanding of the procedure being performed
:Patient consent: the patient's understanding of the procedure matches consent given
:Patient identity confirmed: arm band
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Type: abscess
:Location details: xxx
:Anesthesia: local infiltration
:Local anesthetic: lidocaine 1% with epinephrine
:Anesthetic total: 15 ml
:Patient sedated: no
:Scalpel size: 11
:Incision type: single straight
:Complexity: simple
:Drainage: purulent
:Drainage amount: moderate
:Wound treatment: packed 
:Packing material: iodaform
:Patient tolerance: Patient tolerated the procedure well with no immediate complications.

==Abscess repacking==
:Abscess Repacking by MD
:Performed by: 
:Authorized by: 
:Consent: Verbal consent obtained.
:Patient identity confirmed: arm band
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Type: abscess
:Location details: xxx
:Wound treatment: packed with gauze
:Patient tolerance: Patient tolerated the procedure well with no immediate complications.

==Arthrocentesis==
:Performed by: 
:Authorized by: 
:Consent: Verbal consent obtained. Written consent obtained.
:Risks and benefits: risks, benefits and alternatives were discussed
:Consent given by: patient
:Patient understanding: patient states understanding of the procedure being performed
:Patient consent: the patient's understanding of the procedure matches consent given
:Procedure consent: procedure consent matches procedure scheduled
:Required items: required blood products, implants, devices, and special equipment available
:Patient identity confirmed: arm band and verbally with patient
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Preparation: Patient was prepped and draped in the usual sterile fashion.
:Local anesthesia used: yes
:Anesthesia: local infiltration
:Local anesthetic: lidocaine 1% without epinephrine
:Anesthetic total: 4 ml
:Patient sedated: no
:Location: knee
:Technique: medial approach 
:Patient tolerance: Patient tolerated the procedure well with no immediate complications.
:Comments: X ccs removed without complication

==Cardioversion==
:Performed by: 
:Authorized by: 
:Consent: Verbal consent obtained. Written consent obtained.
:Risks and benefits: risks, benefits and alternatives were discussed
:Consent given by: patient
:Patient understanding: patient states understanding of the procedure being performed
:Patient consent: the patient's understanding of the procedure matches consent given
:Procedure consent: procedure consent matches procedure scheduled
:Required items: required blood products, implants, devices, and special equipment available
:Patient identity confirmed: verbally with patient and arm band
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Sedation type: moderate (conscious) sedation
:Sedatives: propofol
:Analgesia: fentanyl
:Vitals: Vital signs were monitored during sedation.
:Pre-procedure rhythm: atrial fibrillation
:Patient position: patient was placed in a supine position
:Chest area: chest area exposed
:Electrodes: pads
:Electrodes placed: anterior-posterior
:Number of attempts: 1
:Attempt 1 mode: synchronous
:Attempt 1 shock (in Joules): 150
:Post-procedure rhythm: normal sinus rhythm
:Complications: no complications
:Patient tolerance: Patient tolerated the procedure well with no immediate complications.

==Ear Foreign Body==
:Performed by: 
:Authorized by: 
:Consent: Verbal consent obtained.
:Risks and benefits: risks, benefits and alternatives were discussed
:Required items: required blood products, implants, devices, and special equipment available
:Patient identity confirmed: arm band
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Body area: ear
:Localization method: visualized
:Removal mechanism: ear scoop, alligator forceps and balloon extraction, irrigation
:Complexity: complex
:Objects recovered: 1
:Post-procedure assessment: foreign body removed
:Patient tolerance: Patient tolerated the procedure well with no immediate complications

==EJ==
:External Jugular Vein Access
:Performed by: 
:Authorized by: 
:Consent: Verbal consent obtained. 
:Risks and benefits: risks, benefits and alternatives were discussed
:Consent given by: patient
:Patient understanding: patient states understanding of the procedure being performed
:Patient consent: the patient's understanding of the procedure matches consent given
:Patient identity confirmed: verbally with patient and arm band
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Indications: vascular access 
:Preparation: skin prepped with 2% chlorhexidine
:Skin prep agent dried: skin prep agent completely dried prior to procedure
:Location details: right external jugular
:Patient position: Trendelenburg
:Catheter type: IV catheter
:Pre-procedure: landmarks identified
:Successful placement: yes
:Post-procedure: dressing applied
:Assessment: blood return and free fluid flow
:Patient tolerance: Patient tolerated the procedure well with no immediate complications.

==Epistaxis==
:Performed by: 
:Authorized by: 
:Consent: Verbal consent obtained.
:Risks and benefits: risks, benefits and alternatives were discussed
:Consent given by: patient
:Patient understanding: patient states understanding of the procedure being performed
:Required items: required blood products, implants, devices, and special equipment available
:Patient identity confirmed: arm band
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Treatment site: right anterior and right posterior
:Repair method: nasal balloon
:Post-procedure assessment: bleeding stopped
:Treatment complexity: simple
:Patient tolerance: Patient tolerated the procedure well with no immediate complications

==Foreign Body Removal: Eye==
:Performed by: 
:Authorized by: 
:Consent: Verbal consent obtained.
:Risks and benefits: risks, benefits and alternatives were discussed
:Consent given by: patient
:Patient understanding: patient states understanding of the procedure being performed
:Patient consent: the patient's understanding of the procedure matches consent given
:Patient identity confirmed: arm band
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Body area: eye
:Local anesthetic: tetracaine drops
:Anesthetic total: 1 drop
:Patient cooperative: yes
:Localization method: slit lamp
:Removal mechanism: moist cotton swab
:Eye examined with fluorescein.
:Complexity: simple
:Objects recovered: 1
:Post-procedure assessment: foreign body removed
:Patient tolerance: Patient tolerated the procedure well with no immediate complications.
:Comments:

==G-Tube Placement/Replacement==
:Authorized by: 
:Performed by: 
:Consent: Verbal consent obtained.
:Risks and benefits: risks, benefits and alternatives were discussed
:Consent given by: patient and/or guardian
:Patient understanding: patient/guardian states understanding of the procedure being performed
:Patient consent: the patient/guardian's understanding of the procedure matches consent given
:Patient identity confirmed: arm band
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Location details: abdomen
:Procedure: using gentle pressure, new g-tube was placed with normal saline injected afterward to fill balloon port
:Results:  KUB with contrast confirms proper placement
:Complication:  Tolerated well without complication.

==Central Line: IJ==
:Performed by: 
:Authorized by: 
:Consent: Verbal consent obtained. The procedure was performed in an emergent situation.
:Risks and benefits: risks, benefits and alternatives were discussed
:Consent given by: patient
:Patient understanding: patient states understanding of the procedure being performed
:Patient consent: the patient's understanding of the procedure matches consent given
:Procedure consent: procedure consent matches procedure scheduled
:Patient identity confirmed: verbally with patient and arm band
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Indications: vascular access and central pressure monitoring
:Anesthesia: local infiltration
:Local anesthetic: lidocaine 2% with epinephrine
:Anesthetic total: 4 ml
:Preparation: skin prepped with 2% chlorhexidine
:Skin prep agent dried: skin prep agent completely dried prior to procedure
:Sterile barriers: all five maximum sterile barriers used - cap, mask, sterile gown, sterile gloves, and large sterile sheet
:Hand hygiene: hand hygiene performed prior to central venous catheter insertion
:Location details: right internal jugular
:Patient position: Trendelenburg
:Catheter type: triple lumen
:Pre-procedure: landmarks identified
:Ultrasound guidance: yes
:Number of attempts: 1
:Successful placement: yes
:Post-procedure: line sutured and dressing applied
:Assessment: blood return through all parts, free fluid flow, placement verified by x-ray and no pneumothorax on x-ray
:Patient tolerance: Patient tolerated the procedure well with no immediate complications.

==Intubation==
:Performed by: 
:Authorized by: 
:Consent: Verbal consent not obtained. The procedure was performed in an emergent situation.
:Required items: required blood products, implants, devices, and special equipment available
:Patient identity confirmed: arm band
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Indications: respiratory failure and airway protection
:Intubation method: direct
:Patient status: paralyzed (RSI)
:Preoxygenation: BVM and nonrebreather mask
:Sedatives: etomidate
:Paralytic: succinylcoline
:Laryngoscope size: Mac 4
:Tube size: 7.5 mm
:Tube type: cuffed
:Number of attempts: 1
:Cords visualized: yes
:Post-procedure assessment: chest rise,  BS = bilaterally none over epigastrum, +CO2 detector
:Breath sounds: equal and absent over the epigastrium
:Cuff inflated: yes
:ETT to lip: 22 cm
:Tube secured with: adhesive tape
:Chest x-ray interpreted by me.
:Chest x-ray findings: endotracheal tube in appropriate position
:Patient tolerance: Patient tolerated the procedure well with no immediate complications.

==IO Line Placement==
:Performed by: 
:Authorized by: 
:Consent: The procedure was performed in an emergent situation.
:Risks and benefits: risks, benefits and alternatives were discussed
:Patient identity confirmed: arm band
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Indications: rapid vascular access
:Insertion site: right proximal tibia
:Site preparation: chlorhexidine
:Insertion device: drill device
:Insertion: needle was inserted through the bony cortex
:Number of attempts: 1
:Confirmation method: stability of the needle, easy infusion of fluids and aspiration of blood/marrow
:Secured with: protective shield
:Patient tolerance: Patient tolerated the procedure well with no immediate complications

==Laceration==
===Dermabond===
:Lac Repair (with Dermabond)
:Performed by: 
:Authorized by: 
:Consent: Verbal consent obtained.
:Risks and benefits: risks, benefits and alternatives were discussed
:Consent given by: patient
:Patient or guardian understanding: States understanding of the procedure being performed
:Patient or guardian consent: Understanding of the procedure matches consent given
:Patient identity confirmed: arm band and verbally with patient
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Body area: X
:Laceration length: X cm
:Foreign bodies: no foreign bodies
:Tendon involvement: none
:Nerve involvement: none
:Vascular damage: no
:Anesthesia: local infiltration
:Local anesthetic: none
:Anesthetic total: 0 ml
:Patient sedated: no
:Preparation: Patient was prepped and draped in the usual sterile fashion.
:Irrigation solution: saline
:Irrigation method: jet lavage and syringe
:Amount of cleaning: extensive
:Debridement: none
:Degree of undermining: none
:Skin closure: Dermabond
:Number of sutures: NA
:Technique: simple
:Approximation: close
:Approximation difficulty: simple
:Dressing: antibiotic ointment/4x4 gauze
:Patient tolerance: Patient tolerated the procedure well with no immediate complications.

===Standard===
:Lac Repair
:Performed by: DONALDSON, ROSS IRELAND
:Authorized by: DONALDSON, ROSS IRELAND
:Consent: Verbal consent obtained.
:Risks and benefits: risks, benefits and alternatives were discussed
:Consent given by: patient or guardian
:Patient or guardian understanding: patient or guardian states understanding of the procedure being performed
:Patient or guardian consent: the patient or guardian's understanding of the procedure matches consent given
:Patient identity confirmed: arm band and verbally with patient
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Body area: X
:Laceration length: X cm
:Foreign bodies: no foreign bodies
:Tendon involvement: none
:Nerve involvement: none
:Vascular damage: no
:Anesthesia: local infiltration
:Local anesthetic: lidocaine with epinephrine
:Anesthetic total: 4 ml
:Patient sedated: no
:Preparation: Patient was prepped and draped in the usual sterile fashion.
:Irrigation solution: saline
:Irrigation method: jet lavage and syringe
:Amount of cleaning: extensive
:Debridement: none
:Degree of undermining: none
:Skin closure: 6-0 nylon
:Number of sutures: X
:Technique: interupted
:Approximation: close
:Approximation difficulty: simple
:Dressing: antibiotic ointment/4x4 gauze
:Patient tolerance: Patient tolerated the procedure well with no immediate complications.

===Staples===
:Lac Repair with Staples
:Performed by: 
:Authorized by: 
:Consent: Verbal consent obtained.
:Risks and benefits: risks, benefits and alternatives were discussed
:Consent given by: patient
:Patient or guardian understanding: States understanding of the procedure being performed
:Patient or guardian consent: Understanding of the procedure matches consent given
:Patient identity confirmed: arm band and verbally with patient
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Body area: scalp
:Laceration length: X cm
:Foreign bodies: no foreign bodies
:Tendon involvement: none
:Nerve involvement: none
:Vascular damage: no
:Anesthesia: local infiltration
:Local anesthetic: lidocaine with epinephrine
:Anesthetic total: 4 ml
:Patient sedated: no
:Preparation: Patient was prepped and draped in the usual sterile fashion.
:Irrigation solution: saline
:Irrigation method: jet lavage and syringe
:Amount of cleaning: extensive
:Debridement: none
:Degree of undermining: none
:Skin closure: Staples
:Number of staples: X
:Technique: simple
:Approximation: close
:Approximation difficulty: simple
:Dressing: antibiotic ointment/4x4 gauze
:Patient tolerance: Patient tolerated the procedure well with no immediate complications.

==Lumbar Puncture==
:Performed by: 
:Authorized by: 
:Consent: Verbal consent obtained. Written consent obtained.
:Risks and benefits: risks, benefits and alternatives were discussed
:Consent given by: patient
:Patient understanding: patient states understanding of the procedure being performed
:Patient consent: the patient's understanding of the procedure matches consent given
:Procedure consent: procedure consent matches procedure scheduled
:Relevant documents: relevant documents present and verified
:Test results: test results available and properly labeled
:Site marked: the operative site was marked
:Imaging studies: imaging studies available
:Patient identity confirmed: arm band and verbally with patient
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Anesthesia: local infiltration
:Local anesthetic: lidocaine 1% without epinephrine
:Anesthetic total: 4 ml
:Patient sedated: no
:Preparation: Patient was prepped and draped in the usual sterile fashion.
:Lumbar space: L4-L5 interspace
:Patient's position: lateral decubitus
:Needle gauge: 22
:Number of attempts: 1, atraumatic
:Opening pressure: XX cm H2O
:Fluid appearance: clear
:Tubes of fluid: 4
:Total volume: 4 ml
:Post-procedure: site cleaned and pressure dressing applied
:Patient tolerance: Patient tolerated the procedure well with no immediate complications.
:Comments: Nontraumatic

==Orthopedic Nerve Block (Finger)==
:Authorized by: 
:Consent: Verbal consent obtained.
:Risks and benefits: risks, benefits and alternatives were discussed
:Consent given by: patient and/or guardian
:Patient understanding: patient/guardian states understanding of the procedure being performed
:Patient consent: the patient/guardian's understanding of the procedure matches consent given
:Patient identity confirmed: verbally with patient and arm band
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Location details: XXX finger
:Injection: using standard, sterile technique 4 cc of lidocaine without epinepherine injected
:Complication:  Tolerated well without complication.

==Orthopedic Reduction (Nursemaid's elbow)==
:Authorized by: 
:Consent: Verbal consent obtained.
:Risks and benefits: risks, benefits and alternatives were discussed
:Consent given by: Guardian
:Patient understanding: Guardian states understanding of the procedure being performed
:Patient consent: Guardian's understanding of the procedure matches consent given
:Patient identity confirmed: verbally with patient and arm band
:Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
:Location details: arm
:Reduction Procedure: gentle flexion/supination followed by extension/pronation
:Results:  After procedure, the patient was able to move the arm fully without pain.  No TTP.  Issue fully resolved and patient back to normal.
:Complication:  Tolerated well without complication.  DNVI.

==Otitis externa cleaning==
Ear Cleaning with Cerumen Removal and Placement of Ear Wick
Performed by: DONALDSON, ROSS I.
Authorized by: DONALDSON, ROSS I.
Consent: Verbal consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Required items: required blood products, implants, devices, and special equipment available
Patient identity confirmed: arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Body area: ear
Localization method: visualized
Removal mechanism: ear scoop
Placement:  Ear wick
Objects recovered: NA
Post-procedure assessment: copious discharge removed
Patient tolerance: Patient tolerated the procedure well with no immediate complications

==Abscess packing change==
Wound Care by MD (Packing Change)
Performed by: DONALDSON, ROSS I.
Authorized by: DONALDSON, ROSS I.
Consent: Verbal consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient and guardian
Patient understanding: patient states understanding of the procedure being performed
Patient consent: the patient's understanding of the procedure matches consent given
Patient identity confirmed: arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Wound treatment: packing changed
Patient tolerance: Patient tolerated the procedure well with no immediate complications.

==Paracentesis==
Abdominal Paracentesis
Performed by: DONALDSON, ROSS I.
Authorized by: DONALDSON, ROSS I.
Consent: Verbal consent obtained. Written consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient
Patient understanding: patient states understanding of the procedure being performed
Patient consent: the patient's understanding of the procedure matches consent given
Procedure consent: procedure consent matches procedure scheduled
Required items: required blood products, implants, devices, and special equipment available
Patient identity confirmed: arm band and verbally with patient
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Preparation: Patient was prepped and draped in the usual sterile fashion.
Local anesthesia used: yes
Anesthesia: local infiltration
Local anesthetic: lidocaine 1% without epinephrine
Anesthetic total: 4 ml
Patient sedated: no
Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Comments: X liters removed without complication

==Paraphymosis==
Nerve Block (Penis)
Authorized by: DONALDSON, ROSS IRELAND
Performed by: DONALDSON, ROSS IRELAND
Consent: Verbal consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient and/or guardian
Patient understanding: patient/guardian states understanding of the procedure being performed
Patient consent: the patient/guardian's understanding of the procedure matches consent given
Patient identity confirmed: verbally with patient and arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Location details: penis
Injection: using standard, sterile technique 8 cc of lidocaine without epinepherine injected circumferentially 
Complication:  Tolerated well without complication. 

Reduction of Paraphimosis
Authorized by: DONALDSON, ROSS IRELAND
Performed by:: DONALDSON, ROSS IRELAND
Consent: Written consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient and/or guardian
Patient understanding: patient/guardian states understanding of the procedure being performed
Patient consent: the patient/guardian's understanding of the procedure matches consent given
Patient identity confirmed: verbally with patient and arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Location details: penis
Reduction Procedure: Slow direct pressure first applied; followed by reduction using direct pressure
Results:  After procedure, fully reduced.
Complication:  Tolerated well without complication. 

==Paronychia==
Incision/Drainage of Paronychia
Performed by: DONALDSON, ROSS I.
Authorized by: DONALDSON, ROSS I.
Consent: Verbal consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient
Patient understanding: patient states understanding of the procedure being performed
Patient consent: the patient's understanding of the procedure matches consent given
Procedure consent: procedure consent matches procedure scheduled
Patient identity confirmed: verbally with patient and arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Type: abscess
Body area: upper extremity
Location details: XX finger
Anesthesia: nerve block
Local anesthetic: lidocaine 1% without epinephrine
Anesthetic total: 4 ml
Incision type: single straight
Complexity: simple
Drainage: purulent
Drainage amount: mod
Wound treatment: drain placed
Packing material: 1/4 in gauze
Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Comments: With iris sissors, dissected along top of nail.

==PTA==
Incision/Drainage of Peritonsillar Abscess
Performed by: DONALDSON, ROSS I.
Authorized by: DONALDSON, ROSS I.
Consent: Verbal consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient and guardian
Patient understanding: patient states understanding of the procedure being performed
Patient consent: the patient's understanding of the procedure matches consent given
Patient identity confirmed: arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Type: peritonsilar abscess
Location details: right
Anesthesia: local infiltration and spray
Local anesthetic: lidocaine 1% with epinephrine and benzocaine spray
Anesthetic total: 2 ml
Patient sedated: no
Incision type: straight puncture to 1.5 cm with spinal needle covered by plastic cover
Attempts: 3
Drainage:  purulent drainage
Drainage amount: 5cc
Patient tolerance: Patient tolerated the procedure well with no immediate complications.

==Digit reduction==
Orthopedic Reduction (Digit)
Authorized by: DONALDSON, ROSS IRELAND
Performed by: DONALDSON, ROSS IRELAND
Consent: Verbal consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient and/or guardian
Patient understanding: patient/guardian states understanding of the procedure being performed
Patient consent: the patient/guardian's understanding of the procedure matches consent given
Patient identity confirmed: verbally with patient and arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Location details: X
Reduction Procedure: gentle hyperextension and axial pull
Results:  After procedure, digit was fully mobile
Complication:  Tolerated well without complication. <2sec CRT.  Tendons intact.

==Fracture reduction==
Orthopedic Reduction of Fracture
Authorized by: DONALDSON, ROSS IRELAND
Performed by: DONALDSON, ROSS IRELAND
Consent: Verbal consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient and/or guardian
Patient understanding: patient/guardian states understanding of the procedure being performed
Patient consent: the patient/guardian's understanding of the procedure matches consent given
Patient identity confirmed: verbally with patient and arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Location details: ?
Reduction Procedure: axial pull and closed manipulation
Results:  Post reduction alignement improved
Complication:  Tolerated well without complication. <2sec CRT.  Tendons intact.

==Hernia reduction==
Reduction of Hernia
Authorized by: DONALDSON, ROSS IRELAND
Consent: Verbal consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient and/or guardian
Patient understanding: patient/guardian states understanding of the procedure being performed
Patient consent: the patient/guardian's understanding of the procedure matches consent given
Patient identity confirmed: verbally with patient and arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Location details: XX hernia
Reduction Procedure: Direct pressure, constant
Results:  After procedure, fully reduced.  No TTP.  
Complication:  Tolerated well without complication. 

==Procedural sedation==
Conscious Sedation
Authorized by: DONALDSON, ROSS IRELAND
Performed by: DONALDSON, ROSS IRELAND
Consent: Written consent obtained (see nursing note)
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient and/or guardian
Patient understanding: patient/guardian states understanding of the procedure being performed
Patient consent: the patient/guardian's understanding of the procedure matches consent given
Patient identity confirmed: verbally with patient and arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Medication IV: XXX
Complication:  Tolerated well without complication. No hypoxic episodes.
Time:  Total intra-service time with patient was 17 minutes.

==Splint check==
Splint Application and Check
Authorized by: DONALDSON, ROSS IRELAND
Consent: Verbal consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient and parent
Patient understanding: patient states understanding of the procedure being performed
Patient consent: the patient's understanding of the procedure matches consent given
Patient identity confirmed: verbally with patient and arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Location details: XX
Post-procedure: The splinted body part was neurovascularly unchanged following the procedure.
Patient tolerance: Patient tolerated the procedure well with no immediate complications.

==Subungal hematoma==
Incision/Drainage of Subungual Hematoma
Performed by: DONALDSON, ROSS I.
Authorized by: DONALDSON, ROSS I.
Consent: Verbal consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient and guardian
Patient understanding: patient states understanding of the procedure being performed
Patient consent: the patient's understanding of the procedure matches consent given
Patient identity confirmed: arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Type: abscess
Location details: xxx
Anesthesia: NA
Patient sedated: no
Incision type: single with electric cautery
Complexity: simple
Drainage: blood
Drainage amount: moderate
Wound treatment: dressed
Patient tolerance: Patient tolerated the procedure well with no immediate complications.

==Suture removal==
Suture Removal
Performed by: ED Technician
Authorized by: DONALDSON, ROSS IRELAND
Consent: Verbal consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient
Patient understanding: patient states understanding of the procedure being performed
Patient consent: the patient's understanding of the procedure matches consent given
Patient identity confirmed: verbally with patient and arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Body area: XXX
Wound Appearance: clean
Post-removal: Steri-Strips applied and antibiotic ointment applied
Patient tolerance: Patient tolerated the procedure well with no immediate complications.

==Ingrown toenail==
Orthopedic Nerve Block (toe)
Authorized by: DONALDSON, ROSS IRELAND
Consent: Verbal consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient and/or guardian
Patient understanding: patient/guardian states understanding of the procedure being performed
Patient consent: the patient/guardian's understanding of the procedure matches consent given
Patient identity confirmed: verbally with patient and arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Location details: xxx
Injection: using standard, sterile technique 4 cc of lidocaine without epinepherine injected to cover all 4 nerves (2 injections)
Complication:  Tolerated well without complication. 

Toenail Removal
Performed by: DONALDSON, ROSS I.
Authorized by: DONALDSON, ROSS I.
Consent: Verbal consent obtained.
Risks and benefits: risks, benefits and alternatives were discussed
Consent given by: patient and guardian
Patient understanding: patient states understanding of the procedure being performed
Patient consent: the patient's understanding of the procedure matches consent given
Patient identity confirmed: arm band
Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required.
Type: ingrown toenail
Location details: xxx
Procedure:  Below toenail blunt dissected with kelly to base.  Then, peripheral nail clamped and torqued until linear break to base of nail including growth area, and removed.
Complication: None
Wound treatment: 4x4
Patient tolerance: Patient tolerated the procedure well with no immediate complications.

==See Also==
*[[Documentation for emergency physicians]]

[[Category:Documentation]]