Macros (Beta) | My Site

Welcome to the Procedure Documentation Templates Page

This page provides a collection of easy-to-copy, billable procedure templates designed for doctors to quickly and accurately document common and uncommon procedures. These templates are structured to make your workflow more efficient, allowing you to modify, copy, and paste them directly into your notes. Check with your coding department to ensure your macros meet your hospital standards.

How to Use This Page:

Dropdown Menus: Each section contains text dropdowns for different procedures. Simply expand the dropdown for the procedure you need, copy the template, and paste it into your documentation software.
Search Feature: Use Control + F (or Command + F on Mac) to quickly search for a specific procedure or keyword on this page.
Customization: These templates are designed to be flexible. Feel free to modify the details based on your clinical judgment and the patient's specific situation.

Disclaimer:

Use these templates at your own discretion. It is your responsibility to ensure that your documentation meets all applicable legal, regulatory, and clinical standards, including those set forth by your institution, medical board, and billing practices. These templates are not intended to serve as a substitute for individualized medical judgment or professional legal consultation. Each patient encounter is unique, and your documentation must accurately reflect the clinical decision-making, patient condition, and treatments provided in each case.

The use of these templates does not guarantee compliance with billing codes or prevent upcoding, downcoding, or any other discrepancies in reimbursement. We are not liable for any consequences, including but not limited to legal or financial outcomes, arising from the use or misuse of these templates. You must consult with your institution’s compliance department, billing experts, or legal counsel to ensure that your documentation practices meet the necessary requirements for your specific practice and jurisdiction. These templates do not constitute medical or legal advice, and reliance on them without proper professional oversight could result in significant legal and financial liability.

Why I created this page

I created this page because, as a traveling ER doctor, it's incredibly difficult to transfer documentation macros from one hospital or clinic to another. Can you imagine importing every dictation phrase you have at every site you work at? It would take forever. I used to save them in Google Docs, but Google Drive is frequently blocked at many sites. I wanted a quick, reliable way to access all my macros in one place, so I could spend more time on patient care and less time wrestling with documentation. I share this information to help others physicians spend less time with documentation and more time at the bedside providing care.

When I worked in RVU-based shops, accurate and detailed documentation was crucial for billing, but now, as a locum paid hourly, the focus on billing isn't as intense. However, I still prefer to bill at the highest level to demonstrate the value I bring to administration. This way, I can help justify their reimbursement, which may help with job retention—ideally making me the last locum they’d want to leave a site.

Remember, it’s essential to only document what you did and nothing more to maintain integrity in your records.

Let me know if you notice any errors or have any other items you'd like added.

List of searchable content

Procedures

Laceration Repair

Central Line Placement

Endotracheal Intubation

Chest Tube Insertion

Needle Decompression

Pericardiocentesis

Emergency Cricothyrotomy

Arterial Line Placement

Lumbar Puncture

Fracture Care (Splinting/Reduction)

Arthrocentesis (Joint Aspiration)

Cardioversion (Electrical/Chemical)

Moderate Sedation

Incision and Drainage (Abscess)

Foreign Body Removal (Eye/Ear/Nose/Skin)

Wound Care/Debridement

Nail Trephination (Subungual Hematoma)

Foley Catheter Insertion

Reduction of Joint Dislocation (Shoulder/Elbow/Fingers)

Ultrasound-Guided Peripheral IV Placement

Suture Removal

Thoracentesis

Fecal Disimpaction

Testicular Detorsion (Manual)

Vaginal Delivery (Spontaneous)

Perirectal Abscess Drainage

Bartholin Cyst Drainage

Escharotomy (for Burns)

Nasal Foreign Body Removal

Dental Block (for Dental Pain)

Reduction of Paraphimosis

Trephination (Subungual Hematoma)

Penile Block

Peritonsillar Abscess Drainage

Manual Placenta Removal (Postpartum Hemorrhage)

NG Tube Placement

Suprapubic Catheter Insertion

Enucleation (Eye Removal in Trauma)

Burn Care (Debridement and Dressing)

Burn Care (Escharotomy and Dressing)

Lateral Canthotomy (Orbital Compartment Syndrome)

Conscious Sedation

Local/Regional Anesthesia

Nerve Blocks (Digital block, Penile block, Femoral block, etc.)

Intranasal Sedation (for Pediatric Patients)

CPR

Epistaxis

Priapism Drainage

Staple/Suture Removal

Transvenous Pacemaker

Rectal Prolapse Reduction

Vaginal Prolapse Reduction Procedure Note

Blank Procedure Note

MDM

Sepsis Note

Critical Care Time Procedure Note

Stroke Protocol Note

Acute Coronary Syndrome Protocol Note

Respiratory Distress Management Protocol Note

Anaphylaxis Management Protocol Note

Acute Heart Failure Management Protocol Note

Overdose/Poisoning Management Protocol Note

Cardiac Arrest Protocol Note

DKA Management Protocol Note

Postmortem Care and Documentation Note

DNR Discussion and Documentation Note

Withholding/Withdrawal of Care Note

Clinical Decision Calculators

HEART Score / HEART Pathway

NIHSS (National Institutes of Health Stroke Scale)

Wells Criteria for DVT

Wells’ Criteria for Pulmonary Embolism

PERC Rule

PSI/PORT (Pneumonia Severity Index)

CURB-65 Score

Glasgow-Blatchford Score (GBS)

CHA₂DS₂-VASc Score

ABCD² Score

PECARN (Pediatric Emergency Care Applied Research Network)

NEXUS Criteria for C-Spine Imaging

NEXUS Head CT Rule

Canadian CT Head Rule

Glasgow Coma Scale (GCS)

SIRS, Sepsis, and Septic Shock Criteria

qSOFA (Quick SOFA) Score

Procedures

Laceration Repair Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Laceration Length: [Insert length in cm] Location: [Insert location] Shape: Linear / Irregular / Flap / Stellate / Complex / Puncture Depth: Superficial / Subcutaneous / Muscle / Multilayer / Tendon / Fascia Details: Clean / Contaminated / Foreign body present / Contused tissue / Abrasion / Swelling / Erythema / Bleeding / Amputation Neurovascular/Tendon Exam: Intact / Circulation deficit / Motor deficit / Sensory deficit / Tendon deficit Anesthesia: 1% Lidocaine / 2% Lidocaine / Lidocaine with epi / Bicarb / Local / Digital / Regional / LET / TAC / None Amount: [Insert ml] Irrigation: Normal saline / [Other] Debridement: None / Minimal / Moderate / Extensive Skin Closure: [Insert #] sutures, Nylon / Prolene / Staples / Dermabond / Steristrips, Simple / Running / Interrupted Complexity: Single layer / Two-layer / Three-layer / Contaminated Post-Procedure Exam: Circulation, motor, sensory intact Complications: None / [Other] Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Central Line Placement Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: [Insert indication] Site: Right / Left Internal Jugular / Subclavian / Femoral Sterile technique used with chlorhexidine prep, sterile gown, gloves, and drape. Anesthesia: 1% Lidocaine / [Other] Ultrasound Guidance: Yes / No Number of Attempts: [Insert # of attempts] Catheter Type: Triple lumen / Cordis / Introducer / [Other] Length of Catheter: [Insert cm] Guidewire Placement: Successful / Unsuccessful Confirmation of Placement: Aspiration of venous blood / Ultrasound / Chest X-ray / [Other] Complications: None / Arterial puncture / Pneumothorax / Hematoma / [Other] Post-Procedure: Line flushed and patent, sterile dressing applied Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Endotracheal Intubation Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent unable to be obtained due to clinical status / Consent obtained Indication: Respiratory failure / Airway protection / Altered mental status / Other Pre-oxygenation: Bag-valve-mask / Non-rebreather / Nasal cannula Medications: RSI performed with [Insert medication] for sedation and [Insert medication] for paralysis Blade: Mac / Miller, size [Insert size] Tube Size: [Insert tube size] Number of Attempts: [Insert # of attempts] Vocal cords visualized: Yes / No Tube placement confirmed by: Direct visualization / End-tidal CO2 / Auscultation / Chest rise / CXR Post-intubation sedation: [Insert medication] Complications: None / Hypoxia / Esophageal intubation / Bradycardia / [Other] Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Chest Tube Insertion Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient / Unable to obtain due to clinical status Indication: Pneumothorax / Hemothorax / Pleural effusion / Other Site: Right / Left, 4th/5th intercostal space, midaxillary line Sterile technique with chlorhexidine prep, sterile gown, gloves, and drape. Anesthesia: 1% Lidocaine / [Other] Size of Chest Tube: [Insert size in French] Number of Attempts: [Insert # of attempts] Tube placement confirmed by: Return of air/blood/fluid / Chest rise / CXR / Ultrasound Tube connected to water seal / suction Complications: None / Bleeding / Infection / Misplacement / [Other] Post-procedure: Tube secured with sutures, sterile dressing applied Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Needle Decompression Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, side, site Consent: Verbal / Unable to obtain Indication: Tension pneumothorax / Traumatic pneumothorax Site: Right / Left, 2nd intercostal space, midclavicular line Sterile technique, gloves, and chlorhexidine prep applied Needle size: 14-gauge / [Other] Procedure: Needle inserted, immediate release of air confirmed Number of attempts: [Insert number] Complications: None / Bleeding / Infection / Misplacement / [Other] Post-procedure: Patient reassessed, chest rise improved / CXR ordered Patient tolerated: Well Performed by: Myself Total time: [Insert minutes]

Pericardiocentesis Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, side, site Consent: Verbal / Unable to obtain Indication: Pericardial tamponade / Suspicion of pericardial effusion Site: Subxiphoid / Left parasternal approach Sterile technique with chlorhexidine prep, sterile gloves applied Anesthesia: Local with 1% Lidocaine / [Other] Procedure: Needle inserted at [Insert angle], fluid aspirated Amount of fluid removed: [Insert volume in mL] Fluid appearance: Clear / Bloody / Serous Confirmation of needle placement: Ultrasound / ECG changes Complications: None / Bleeding / Arrhythmia / [Other] Post-procedure: Patient reassessed, vitals stable, repeat ultrasound performed Patient tolerated: Well Performed by: Myself Total time: [Insert minutes]

Emergency Cricothyrotomy Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, side, site Consent: Verbal / Unable to obtain due to clinical status Indication: Failed airway / Inability to intubate / Severe airway obstruction Site: Cricothyroid membrane Sterile technique with chlorhexidine prep, sterile gloves, and drape applied Anesthesia: Local with 1% Lidocaine / None Procedure: Vertical incision made, cricothyroid membrane palpated, horizontal incision made, tracheostomy tube inserted and secured Tube size: [Insert size] Number of attempts: [Insert number] Confirmation of tube placement: Bilateral chest rise / Capnography / Auscultation Complications: None / Bleeding / Infection / Subcutaneous emphysema / [Other] Post-procedure: Tube secured, patient ventilated Patient tolerated: Well Performed by: Myself Total time: [Insert minutes]

Arterial Line Placement Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, side, site Consent: Verbal / Unable to obtain Indication: Hemodynamic monitoring / Frequent blood gas analysis Site: Right / Left radial artery / Femoral artery / Other Sterile technique with chlorhexidine prep, sterile gloves, and drape applied Anesthesia: Local with 1% Lidocaine / None Procedure: Needle inserted into artery, guidewire advanced, catheter placed Arterial waveform confirmed on monitor Number of attempts: [Insert number] Complications: None / Bleeding / Infection / Thrombosis / [Other] Post-procedure: Catheter secured, sterile dressing applied, arterial waveform confirmed Patient tolerated: Well Performed by: Myself Total time: [Insert minutes]

Lumbar Puncture Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Suspected meningitis / Subarachnoid hemorrhage / Idiopathic intracranial hypertension / Other Position: Lateral decubitus / Sitting Site: L3-L4 / L4-L5 interspace Sterile technique with chlorhexidine prep, sterile gown, gloves, and drape. Anesthesia: 1% Lidocaine / [Other] Needle Size: [Insert needle size] Number of Attempts: [Insert # of attempts] CSF Obtained: Yes / No Opening Pressure: [Insert pressure] CSF Appearance: Clear / Cloudy / Bloody / Xanthochromic Samples sent for: Cell count / Glucose / Protein / Culture / Other Complications: None / Bloody tap / Post-LP headache / Infection / [Other] Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Fracture Care (Splinting/Reduction) Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Fracture of [Insert bone], confirmed by X-ray Type of Fracture: Closed / Open Location: Proximal / Mid-shaft / Distal Laterality: Right / Left Neurovascular exam: Intact / Circulation deficit / Sensory deficit / Motor deficit Anesthesia: Local with 1% Lidocaine / Sedation / None Reduction: Successful / Unsuccessful Number of Attempts: [Insert # of attempts] Method: Closed reduction / Traction / Manipulation / [Other] Splint Applied: Yes / No Type of Splint: Sugar tong / U-slab / Short arm / Long arm / Short leg / Long leg / Thumb spica / [Other] Post-reduction X-ray: Confirmed reduction / Malalignment / [Other findings] Post-procedure neurovascular exam: Intact / Circulation deficit / Sensory deficit / Motor deficit Complications: None / [Other] Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Paracentesis Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Ascites / Diagnostic evaluation / Therapeutic removal of fluid / Other Site: Right / Left lower quadrant Sterile technique with chlorhexidine prep, sterile gown, gloves, and drape. Anesthesia: 1% Lidocaine / [Other] Needle Size: [Insert needle size] Amount of Fluid Removed: [Insert volume in mL] Fluid Appearance: Clear / Cloudy / Bloody Samples sent for: Cell count / Albumin / Culture / Gram stain / Other Complications: None / Infection / Bleeding / Bowel perforation / [Other] Post-procedure: Site covered with sterile dressing, patient monitored for complications Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Thoracentesis Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Pleural effusion / Diagnostic evaluation / Therapeutic removal of fluid / Other Site: Right / Left, [Insert intercostal space] Sterile technique with chlorhexidine prep, sterile gown, gloves, and drape. Anesthesia: 1% Lidocaine / [Other] Needle Size: [Insert needle size] Amount of Fluid Removed: [Insert volume in mL] Fluid Appearance: Clear / Serosanguinous / Bloody / Purulent Samples sent for: Cell count / Protein / LDH / Culture / Cytology / Other Complications: None / Pneumothorax / Bleeding / Infection / [Other] Post-procedure: Chest X-ray performed to confirm no pneumothorax, site covered with sterile dressing Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Arthrocentesis (Joint Aspiration) Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Joint effusion / Suspected septic arthritis / Gout / Diagnostic / Therapeutic Site: Shoulder / Elbow / Wrist / Knee / Ankle / Other Sterile technique with chlorhexidine prep, sterile gown, gloves, and drape. Anesthesia: 1% Lidocaine / [Other] Needle Size: [Insert needle size] Amount of Fluid Removed: [Insert volume in mL] Fluid Appearance: Clear / Cloudy / Bloody / Purulent Samples sent for: Cell count / Crystals / Gram stain / Culture / Other Complications: None / Bleeding / Infection / [Other] Post-procedure: Sterile dressing applied to the site, patient monitored for complications Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Cardioversion Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Atrial fibrillation / Atrial flutter / Supraventricular tachycardia / Ventricular tachycardia / Other Type: Electrical / Chemical For Electrical Cardioversion: Energy: [Insert joules] Pads placed in anterior-posterior / anterior-lateral position Sedation: [Insert sedation agent] Number of shocks: [Insert # of shocks] Rhythm post-cardioversion: Normal sinus rhythm / [Other] For Chemical Cardioversion: Medication: [Adenosine / Amiodarone / Diltiazem / Other] Dose: [Insert dose] Rhythm post-cardioversion: Normal sinus rhythm / [Other] Complications: None / Hypotension / Bradycardia / Arrhythmia / [Other] Post-procedure: Continuous cardiac monitoring, patient monitored for stability Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Conscious/Moderate Sedation Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Reduction of fracture / Cardioversion / Abscess drainage / Other Sedation Medications: [Midazolam / Fentanyl / Ketamine / Propofol / Other] Dose: [Insert dose] Route: IV / IM / Other Monitoring: Continuous pulse oximetry, cardiac monitoring, BP every [Insert time] minutes Oxygen: Nasal cannula / Non-rebreather / Bag-valve-mask / [Other] Start Time: [Insert start time] End Time: [Insert end time] Sedation Level: Minimal / Moderate / Deep Complications: None / Hypoxia / Hypotension / Bradycardia / [Other] Post-procedure: Patient recovered to baseline, vitals stable, patient monitored in recovery Discharge Instructions: Given to patient or caregiver, patient to follow-up as needed Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Sedation Time: [Insert minutes]

Incision and Drainage (Abscess) Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Abscess Location: [Insert location] Size: [Insert size] Anesthesia: Local with 1% Lidocaine / [Other] Sterile technique with chlorhexidine prep, sterile gown, gloves, and drape. Incision made with [Insert instrument] Amount of pus drained: [Insert amount] Culture obtained: Yes / No Irrigation: Normal saline / [Other] Packing: Yes / No, with [Insert packing material] Complications: None / Bleeding / Infection / [Other] Post-procedure: Sterile dressing applied, patient advised to return if signs of infection or worsening symptoms Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Foreign Body Removal Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Foreign body in [Eye / Ear / Nose / Skin / Other] Location: [Insert location] Type of Foreign Body: Metal / Wood / Glass / Organic material / Other Anesthesia: Local with 1% Lidocaine / None / [Other] Sterile technique with chlorhexidine prep, sterile gown, gloves, and drape. Method of Removal: Forceps / Irrigation / Suction / Magnet / [Other] Complications: None / Bleeding / Infection / Residual foreign body / [Other] Post-procedure: Sterile dressing applied (if applicable), patient advised on signs of infection or complications Follow-up: [Insert follow-up instructions] Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Wound Care/Debridement Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Wound requiring debridement / Necrotic tissue / Infected wound Location: [Insert location] Size of Wound: [Insert size] Anesthesia: Local with 1% Lidocaine / None / [Other] Sterile technique with chlorhexidine prep, sterile gown, gloves, and drape. Type of Debridement: Sharp / Mechanical / Enzymatic / Autolytic Extent of Debridement: Minimal / Moderate / Extensive Tissue Removed: Necrotic / Infected / Foreign material / Other Complications: None / Bleeding / Infection / [Other] Post-procedure: Wound cleaned and dressed with [Insert dressing], patient advised on wound care instructions and signs of infection Follow-up: [Insert follow-up instructions] Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Nail Trephination (Subungual Hematoma) Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Subungual hematoma Location: [Insert finger/toe] Size of Hematoma: [Insert size] Anesthesia: Local with 1% Lidocaine / None / [Other] Sterile technique with alcohol prep, sterile gloves. Method: Electrocautery / Needle / Paperclip / [Other] Relief of Pressure: Successful / Unsuccessful Amount of Blood Drained: [Insert amount] Complications: None / Infection / Nail bed injury / [Other] Post-procedure: Sterile dressing applied, patient advised on signs of infection or nail loss Follow-up: [Insert follow-up instructions] Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Foley Catheter Insertion Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Urinary retention / Monitoring urine output / Other Sterile technique with chlorhexidine prep, sterile gloves, and drape. Catheter Size: [Insert French size] Number of Attempts: [Insert # of attempts] Balloon inflated with [Insert mL of sterile water] Urine Output: [Insert volume of urine obtained, if any] Complications: None / Urethral trauma / Infection / [Other] Post-procedure: Catheter secured, urine bag attached Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Suture Removal Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Removal of sutures from [Insert location] Number of Sutures Removed: [Insert # of sutures] Wound Appearance: Well-healed / Redness / Drainage / Swelling / [Other] Complications: None / Wound dehiscence / Infection / [Other] Post-procedure: Sterile dressing applied, patient advised on wound care and follow-up as needed Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Ultrasound-Guided Peripheral IV Placement Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Difficult IV access / Need for IV fluids / Medications Site: Right / Left [Insert location] Sterile technique with chlorhexidine prep, sterile gloves. Ultrasound used to visualize vein: Yes / No Catheter Size: [Insert gauge size] Number of Attempts: [Insert # of attempts] Successful cannulation: Yes / No Complications: None / Bleeding / Infection / [Other] Post-procedure: IV flushed and patent, secured with sterile dressing Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Reduction of Joint Dislocation Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Dislocation of [Shoulder / Elbow / Finger / Hip / Knee / Other] Side: Right / Left Neurovascular Exam Pre-reduction: Intact / Circulation deficit / Sensory deficit / Motor deficit Anesthesia: Local with 1% Lidocaine / Sedation / None / [Other] Reduction Method: Traction / Counter-traction / External rotation / Stimson / [Other] Number of Attempts: [Insert # of attempts] Post-reduction X-ray: Confirmed reduction / Malalignment / Fracture / [Other] Post-reduction Neurovascular Exam: Intact / Circulation deficit / Sensory deficit / Motor deficit Complications: None / Fracture / Neurovascular injury / [Other] Post-procedure: Immobilization with sling / splint, patient advised on follow-up Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Pelvic Exam Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Abdominal pain / Vaginal bleeding / Suspected infection / Other Position: Lithotomy External Genitalia: Normal / Lesions / Erythema / Swelling / [Other] Vaginal Vault: Normal / Discharge / Blood / Lesions / [Other] Cervix: Closed / Open / Erythematous / Discharge / Lesions Bimanual Exam: Uterus normal size / Adnexal tenderness / Cervical motion tenderness / [Other] Samples Obtained: Wet mount / GC/Chlamydia swab / Pap smear / [Other] Complications: None / Patient discomfort / Bleeding / [Other] Post-procedure: Patient advised on follow-up for lab results and further care Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Nasal Packing (for Epistaxis) Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Epistaxis (Nosebleed) Side: Right / Left / Bilateral Nasal cavity examined and actively bleeding site identified: Yes / No Bleeding controlled with: Direct pressure / Vasoconstrictive agent (Afrin, Cocaine, Lidocaine with epinephrine) / Cautery (Silver nitrate) / [Other] Type of packing: Merocel / Rapid Rhino / Cotton ball with epinephrine / Gauze strip / [Other] Length of packing: [Insert cm] Complications: None / Discomfort / Infection / [Other] Post-procedure: Patient advised to return if bleeding persists, follow-up with ENT arranged Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Thoracentesis Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Pleural effusion / Diagnostic evaluation / Therapeutic removal of fluid / Other Site: Right / Left, [Insert intercostal space] Sterile technique with chlorhexidine prep, sterile gown, gloves, and drape. Anesthesia: 1% Lidocaine / [Other] Needle Size: [Insert needle size] Amount of Fluid Removed: [Insert volume in mL] Fluid Appearance: Clear / Serosanguinous / Bloody / Purulent Samples sent for: Cell count / Protein / LDH / Culture / Cytology / Other Complications: None / Pneumothorax / Bleeding / Infection / [Other] Post-procedure: Chest X-ray performed to confirm no pneumothorax, site covered with sterile dressing Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Fecal Disimpaction Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Constipation / Fecal impaction / Incomplete bowel evacuation Patient Position: Left lateral / Lithotomy / Other Sterile technique with gloves and lubricant applied. Method: Manual disimpaction with finger / Instrument-assisted Amount of stool removed: [Insert amount] Stool consistency: Hard / Soft / Mixed / Other Complications: None / Bleeding / Rectal pain / [Other] Post-procedure: Patient advised on bowel care regimen and follow-up if symptoms persist Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Testicular Detorsion Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Suspected testicular torsion Side: Right / Left Pre-procedure exam: Testicle high-riding / Absent cremasteric reflex / Swelling / Tenderness Sterile technique with gloves applied. Method: Manual detorsion attempted by rotating testicle laterally (outward) / [Other] Number of Attempts: [Insert # of attempts] Post-procedure exam: Testicle lower / Improved blood flow / Pain relief / Persistent symptoms Confirmation of Detorsion: Doppler ultrasound / Clinical improvement Complications: None / Persistent torsion / [Other] Post-procedure: Patient advised to follow-up with urology for definitive management (surgery) Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Vaginal Delivery (Spontaneous) Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Full-term pregnancy / Preterm labor / [Other] Gestational Age: [Insert weeks] Position of Patient: Lithotomy Sterile technique with drapes, gown, gloves, and mask applied. Stage of Labor: Active / Transition Fetal Position: Cephalic / Breech / [Other] Delivery: Normal spontaneous vaginal delivery with head delivered first, followed by shoulders and body Episiotomy: None / Performed (Type: Mediolateral / Midline) Perineal Tear: None / First-degree / Second-degree / Third-degree / Fourth-degree Cord Clamping: Delayed / Immediate Placenta Delivery: Spontaneous / Assisted (Manual removal) Placenta Appearance: Intact / Retained fragments Post-delivery Uterine Tone: Firm / Boggy Postpartum Bleeding: Normal / Excessive Complications: None / Shoulder dystocia / Postpartum hemorrhage / Fetal distress / [Other] Post-procedure: Fundal massage performed, patient monitored for postpartum hemorrhage, baby handed to pediatric team for care Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Perirectal Abscess Drainage Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Perirectal abscess Location: Right / Left / [Insert location] Size: [Insert size] Anesthesia: Local with 1% Lidocaine / [Other] Sterile technique with chlorhexidine prep, sterile gown, gloves, and drape. Incision made with [Insert instrument] Amount of pus drained: [Insert amount] Culture obtained: Yes / No Irrigation: Normal saline / [Other] Packing: Yes / No, with [Insert packing material] Complications: None / Bleeding / Infection / [Other] Post-procedure: Sterile dressing applied, patient advised on wound care and follow-up if symptoms worsen Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Bartholin Cyst Drainage Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Bartholin gland cyst / Abscess Side: Right / Left Size: [Insert size] Anesthesia: Local with 1% Lidocaine / [Other] Sterile technique with chlorhexidine prep, sterile gown, gloves, and drape. Incision made with [Insert instrument] Amount of pus/fluid drained: [Insert amount] Culture obtained: Yes / No Word catheter placed: Yes / No Packing: Yes / No Complications: None / Bleeding / Infection / [Other] Post-procedure: Sterile dressing applied, patient advised on wound care and catheter care Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Escharotomy Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient / Unable to obtain due to clinical status Indication: Full-thickness circumferential burn / Compartment syndrome / Impaired circulation Location: [Insert location] Sterile technique with chlorhexidine prep, sterile gown, gloves, and drape. Anesthesia: Local with 1% Lidocaine / Sedation / [Other] Incision made along the length of the burn eschar, ensuring release of pressure Depth of incision: Through eschar, down to subcutaneous tissue Number of incisions: [Insert number] Improved circulation confirmed by: Improved pulses / Decreased pressure / [Other] Complications: None / Bleeding / Infection / [Other] Post-procedure: Sterile dressing applied, patient monitored for return of compartment symptoms Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Nasal Foreign Body Removal Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient / Guardian Indication: Foreign body in nostril Side: Right / Left Type of Foreign Body: Metal / Organic / Plastic / [Other] Anesthesia: Topical anesthetic with 1% Lidocaine / None / [Other] Sterile technique with gloves and instruments used. Method of Removal: Forceps / Suction / Positive pressure / Katz extractor / Balloon catheter / [Other] Number of Attempts: [Insert # of attempts] Complications: None / Bleeding / Mucosal injury / [Other] Post-procedure: Patient monitored for complications, advised on follow-up if needed Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Dental Block Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Dental pain / Fractured tooth / Abscess / Other Side: Right / Left / Upper / Lower Anesthesia: 1% Lidocaine / 2% Lidocaine with epinephrine / [Other] Technique: Inferior alveolar nerve block / Mental nerve block / Maxillary nerve block / [Other] Number of Attempts: [Insert # of attempts] Effectiveness: Pain relief achieved / Partial relief / No relief Complications: None / Bleeding / Nerve injury / [Other] Post-procedure: Patient advised to avoid biting or chewing on the anesthetized side, follow-up with dentist recommended Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Reduction of Paraphimosis Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Paraphimosis Anesthesia: Local with 1% Lidocaine / None / [Other] Method: Manual reduction with lubrication and gentle compression of the glans / Osmotic technique with sugar / Ice application / [Other] Number of Attempts: [Insert # of attempts] Post-reduction exam: Foreskin returned to normal position / Swelling reduced / Improved circulation Complications: None / Persistent swelling / Pain / [Other] Post-procedure: Patient advised on hygiene, to avoid retraction of foreskin, follow-up with urology recommended Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Trephination (Subungual Hematoma) Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Subungual hematoma Location: [Insert finger/toe] Anesthesia: Local with 1% Lidocaine / None / [Other] Sterile technique with gloves and instruments used. Method: Electrocautery / Needle / Paperclip / [Other] Relief of Pressure: Successful / Unsuccessful Amount of Blood Drained: [Insert amount] Complications: None / Infection / Nail bed injury / [Other] Post-procedure: Sterile dressing applied, patient advised on signs of infection and follow-up if symptoms persist Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Penile Block Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Circumcision / Genital trauma / Pain management for penile procedure / Other Anesthesia: 1% Lidocaine without epinephrine / [Other] Technique: Dorsal nerve block / Ring block Number of Attempts: [Insert # of attempts] Effectiveness: Complete pain relief / Partial relief / No relief Complications: None / Bleeding / Infection / Nerve injury / [Other] Post-procedure: Patient advised on post-procedure care and follow-up if symptoms persist Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Peritonsillar Abscess Drainage Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Peritonsillar abscess Side: Right / Left Anesthesia: Local with 1% Lidocaine / Topical anesthetic spray / [Other] Sterile technique with gloves and instruments used. Incision made with [Insert instrument] Amount of pus drained: [Insert amount] Culture obtained: Yes / No Complications: None / Bleeding / Aspiration / [Other] Post-procedure: Patient advised on post-drainage care, antibiotics prescribed, follow-up with ENT arranged Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Manual Placenta Removal Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient / Unable to obtain due to clinical status Indication: Retained placenta / Postpartum hemorrhage Anesthesia: Local with 1% Lidocaine / Sedation / [Other] Sterile technique with gloves, gown, and drape used. Method: Manual removal of retained placenta with gentle traction / [Other] Placenta removed in: Intact / Fragmented pieces Amount of Blood Loss: [Insert volume] Uterine Tone Post-removal: Firm / Boggy Complications: None / Uterine atony / Hemorrhage / [Other] Post-procedure: Uterine massage performed, Oxytocin administered, patient monitored for ongoing hemorrhage Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

NG Tube Placement Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Bowel obstruction / Gastric decompression / Aspiration of gastric contents / Other Anesthesia: Topical anesthetic spray / None Technique: NG tube inserted through the nasal passage, advanced into the stomach under direct visualization Tube Size: [Insert size] Number of Attempts: [Insert # of attempts] Confirmation of Placement: Aspiration of gastric contents / Auscultation / X-ray Complications: None / Bleeding / Nasal trauma / Malposition / [Other] Post-procedure: Tube secured, patient monitored, instructions given for continued use Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Suprapubic Catheter Insertion Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient / Unable to obtain due to clinical status Indication: Urinary retention / Urethral injury / Long-term catheterization / Other Anesthesia: Local with 1% Lidocaine / Sedation / [Other] Sterile technique with chlorhexidine prep, sterile gown, gloves, and drape. Catheter Size: [Insert size in French] Needle and catheter introduced through lower abdomen into the bladder Confirmation of placement by: Aspiration of urine / Ultrasound / [Other] Complications: None / Bleeding / Infection / Bowel perforation / [Other] Post-procedure: Catheter secured, urine bag attached, patient monitored Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Enucleation Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient / Unable to obtain due to clinical status Indication: Severe ocular trauma / Ruptured globe / Malignant tumor / Infection / Other Side: Right / Left Anesthesia: General anesthesia / Local with sedation / [Other] Sterile technique with drapes, gown, gloves, and mask applied. Eye removed intact / Debris cleaned from orbit Hemostasis achieved with cautery / [Other] Prosthesis: Inserted / Not inserted Complications: None / Bleeding / Infection / [Other] Post-procedure: Pressure dressing applied, patient monitored for complications, follow-up with ophthalmology arranged Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Burn Care (Debridement and Dressing) Procedure Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent provided by patient Indication: Partial-thickness burn / Full-thickness burn / Other Location: [Insert location] Size of Burn: [Insert size] Anesthesia: Local with 1% Lidocaine / None / [Other] Sterile technique with gloves, gown, and drape applied. Debridement: Minimal / Moderate / Extensive Type of Debridement: Sharp / Mechanical / Enzymatic / [Other] Tissue Removed: Necrotic / Infected / [Other] Dressing Applied: Silver sulfadiazine / Bacitracin / Mepilex / [Other] Post-procedure: Wound covered with sterile dressing, patient instructed on burn care and follow-up Complications: None / Bleeding / Infection / [Other] Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Burn Care (Escharotomy and Dressing) Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, side, site Consent: Verbal / Unable to obtain Indication: Full-thickness circumferential burn / Compartment syndrome Site: Right / Left upper limb / Lower limb / Chest / [Insert location] Sterile technique with chlorhexidine prep, sterile gloves, and drape applied Anesthesia: Local with 1% Lidocaine / None / [Other] Procedure: Incision made along the length of the eschar down to subcutaneous tissue, ensuring release of pressure Number of incisions: [Insert number] Immediate improvement in circulation: Yes / No Post-procedure dressing applied: Sterile gauze / [Other] Complications: None / Bleeding / Infection / [Other] Post-procedure: Patient reassessed for compartment pressure relief and circulation Patient tolerated: Well Performed by: Myself Total time: [Insert minutes]

Lateral Canthotomy Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, side, site Consent: Verbal / Unable to obtain Indication: Orbital compartment syndrome / Retrobulbar hemorrhage Site: Right / Left eye, lateral canthus Sterile technique with chlorhexidine prep, sterile gloves applied Anesthesia: Local with 1% Lidocaine / None Procedure: Lateral canthal tendon incised, pressure immediately relieved Intraocular pressure pre-procedure: [Insert value] Intraocular pressure post-procedure: [Insert value] Number of attempts: [Insert number] Complications: None / Bleeding / Infection / [Other] Post-procedure: Patient reassessed, eye swelling and pressure improved Patient tolerated: Well Performed by: Myself Total time: [Insert minutes]

Conscious Sedation Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, time out Consent: Patient / parent / legal guardian / signed / verbal Indication: Closed reduction / fracture manipulation / laceration repair / incision drainage / cardioversion Monitoring: Cardiac, blood pressure, pulse oximetry Preparation: Suction, IV access, constant attendance, supplemental oxygen ASA Class: 1 healthy patient / 2 mild systemic disease / 3 severe systemic disease NON-threatening / 4 severe systemic disease / 5 not expected to live 24 hours Mallampati score: 1 complete soft palate / 2 most of uvula / 3 base of uvula / 4 soft palate not visible Physical exam: [Please see physical exam] Pre-sedation vital signs: [Please see nursing documentation] Procedural Sedation: Medication: Propofol / Ketamine / Etomidate / Versed / Fentanyl [Insert dose], IV / IM / PO / IN Patient tolerated: Well Complications: None Performed by: Myself Total intraservice time: [Insert minutes] Notes: Sedation protocol followed. Nurse and respiratory therapist were both present during the sedation and monitored vital signs and cardiorespiratory monitors.

Local/Regional Anesthesia Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, time out Consent: Patient / parent / legal guardian / signed / verbal Indication: Laceration repair / Fracture reduction / Incision and drainage / [Other] Monitoring: Cardiac, blood pressure, pulse oximetry (if applicable) Preparation: Suction, IV access, constant attendance (if applicable), supplemental oxygen (if applicable) ASA Class: 1 healthy patient / 2 mild systemic disease / 3 severe systemic disease NON-threatening / 4 severe systemic disease / 5 not expected to live 24 hours Mallampati score: 1 complete soft palate / 2 most of uvula / 3 base of uvula / 4 soft palate not visible Physical exam: [Please see physical exam] Pre-anesthesia vital signs: [Please see nursing documentation] Anesthesia Administered: Local / Regional Medication: Lidocaine / Lidocaine with epinephrine / Bupivacaine / [Other] Route: Local infiltration / Nerve block / [Other] Dose: [Insert dose] Patient tolerated: Well Complications: None Performed by: Myself Total intraservice time: [17 minutes] Notes: Procedure performed without complications. Patient monitored for signs of adverse reactions, and no issues were noted.

Nerve Block Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, time out Consent: Patient / parent / legal guardian / signed / verbal Indication: Pain control for fracture reduction / Laceration repair / Post-procedure pain / [Other] Monitoring: Cardiac, blood pressure, pulse oximetry (if applicable) Preparation: Suction, IV access, constant attendance (if applicable), supplemental oxygen (if applicable) ASA Class: 1 healthy patient / 2 mild systemic disease / 3 severe systemic disease NON-threatening / 4 severe systemic disease / 5 not expected to live 24 hours Mallampati score: 1 complete soft palate / 2 most of uvula / 3 base of uvula / 4 soft palate not visible Physical exam: [Please see physical exam] Pre-block vital signs: [Please see nursing documentation] Nerve Block Administered: Digital block / Penile block / Femoral block / [Other] Medication: Lidocaine / Lidocaine with epinephrine / Bupivacaine / [Other] Dose: [Insert dose] Route: Local infiltration / [Other] Patient tolerated: Well Complications: None Performed by: Myself Total intraservice time: [17 minutes] Notes: Procedure performed without complications. Patient monitored for signs of adverse reactions, and no issues were noted.

Intranasal Sedation Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, time out Consent: Patient / parent / legal guardian / signed / verbal Indication: Laceration repair / Fracture reduction / Pain control / [Other] Monitoring: Cardiac, blood pressure, pulse oximetry Preparation: Suction, IV access (if applicable), constant attendance, supplemental oxygen (if applicable) ASA Class: 1 healthy patient / 2 mild systemic disease / 3 severe systemic disease NON-threatening / 4 severe systemic disease / 5 not expected to live 24 hours Mallampati score: 1 complete soft palate / 2 most of uvula / 3 base of uvula / 4 soft palate not visible Physical exam: [Please see physical exam] Pre-sedation vital signs: [Please see nursing documentation] Intranasal Sedation Administered: Medication: Ketamine / Midazolam / Fentanyl / [Other] Dose: [Insert dose] Route: Intranasal Patient tolerated: Well Complications: None Performed by: Myself Total intraservice time: [17 minutes] Notes: Procedure performed without complications. Patient monitored for signs of adverse reactions, and no issues were noted.

CPR Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, time Consent: Unable to obtain due to emergent situation Indication: Cardiac arrest (PEA / VFib / VTach / Asystole) CPR initiated at [Insert time] Number of cycles: [Insert # of cycles] Defibrillation: Yes / No, [Insert #] shocks delivered at [Insert joules] Airway management: Intubated / BVM / Supraglottic airway IV/IO access obtained: Yes / No Medications administered: Epinephrine [Insert dose], Amiodarone [Insert dose], Other: [Insert medications] ROSC (Return of Spontaneous Circulation): Yes / No Time of ROSC: [Insert time] Complications: None / Rib fractures / Pneumothorax / [Other] Outcome: Patient stabilized / Expired Performed by: Myself Total time: [Insert minutes]

Epistaxis Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, time Consent: Verbal / Unable to obtain Indication: Active nasal bleeding / Recurrent epistaxis Initial intervention: Direct pressure applied for [Insert minutes] Nasal packing: Yes / No Type: Merocel / Rapid Rhino / Gauze Vasoconstrictive agent used: Afrin / Lidocaine with epinephrine / Other Cautery performed: Yes / No Type: Silver nitrate / Electrical Bleeding control achieved: Yes / No Complications: None / Rebleeding / Discomfort Patient tolerated: Well Performed by: Myself Total time: [Insert minutes]

Priapism Drainage Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, time Consent: Verbal / Unable to obtain Indication: Ischemic priapism / Persistent painful erection Procedure: Penile shaft prepped with sterile technique. Local anesthesia: 1% Lidocaine [Insert amount]. 19 or 21-gauge butterfly needle inserted into the lateral aspect of the corpus cavernosum. Aspiration performed, and [Insert volume] mL of blood removed. Irrigation: Saline / Phenylephrine [Insert dose] administered if applicable Response to procedure: Detumescence achieved / Partial relief / No relief Complications: None / Hematoma / Infection / Other Patient tolerated: Well Performed by: Myself Total time: [Insert minutes]

Staple/Suture Removal Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, site Consent: Verbal / Unable to obtain Indication: Routine staple/suture removal after wound healing Procedure: Area cleansed with sterile solution. Staples / sutures removed using [Insert instrument]. Wound examined for infection, dehiscence, or complications. Wound condition: Healed / Partial healing / Signs of infection / Dehiscence Dressing applied: Sterile dressing / None Complications: None / Bleeding / Infection / Dehiscence Patient tolerated: Well Performed by: Myself Total time: [Insert minutes]

Transvenous Pacemaker Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, side, site Consent: Verbal / Unable to obtain Indication: Bradycardia / Complete heart block / Unstable arrhythmia Procedure: Sterile technique used. Right internal jugular / subclavian / femoral vein cannulated. Introduced pacing catheter advanced under fluoroscopy / EKG guidance into the right ventricle. Pacing wire connected to external pacemaker. Pacing rate set at: [Insert rate] Capture achieved: Yes / No Threshold: [Insert threshold in milliamps] Complications: None / Arrhythmia / Infection / Pneumothorax / Other Patient tolerated: Well Performed by: Myself Total time: [Insert minutes]

Rectal Prolapse Reduction Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, time Consent: Verbal / Unable to obtain Indication: Rectal prolapse Procedure: Patient placed in lithotomy / prone position. Prolapsed rectal tissue cleansed and lubricated. Manual reduction performed using gentle pressure with gauze and lubrication. Reduction successful: Yes / No Post-reduction exam: Good perfusion / Swelling / Tissue necrosis Dressing applied: Moist gauze / None Complications: None / Recurrence / Strangulation / Other Patient tolerated: Well Performed by: Myself Total time: [Insert minutes]

Vaginal Prolapse Reduction Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, time Consent: Verbal / Unable to obtain Indication: Vaginal prolapse Procedure: Patient placed in lithotomy position. Prolapsed vaginal tissue cleansed and lubricated. Manual reduction performed using gentle pressure with gauze and lubrication. Reduction successful: Yes / No Post-reduction exam: Good perfusion / Swelling / Tissue necrosis Dressing applied: Moist gauze / None Complications: None / Recurrence / Strangulation / Other Patient tolerated: Well Performed by: Myself Total time: [Insert minutes]

Blank Procedure Note Time: [Insert time] Confirmed correct: Patient, procedure, side, site Consent: Verbal / Written / Unable to obtain Indication: [Insert indication] Procedure: [Insert description of the procedure performed] Anesthesia: [Type of anesthesia used / None] Number of attempts: [Insert number of attempts] Complications: None / [Insert complications] Patient tolerated: Well Performed by: Myself Total time: [Insert minutes]

MDM

Sepsis Note Based on the patient's presentation, I believe the patient has sepsis, as they have SIRS and a suspected infection. For Severe Sepsis, the patient presents with sepsis causing at least one acute organ dysfunction (e.g., lactate >2.0, SBP <90, MAP 2.0, bilirubin >2.0, platelets 1.5, PTT >60). For Septic Shock, the patient is septic with a lactate ≥4 or is hypotensive despite fluid resuscitation. Severe Sepsis Time Zero: Blood cultures and initial lactate were obtained. Broad-spectrum IV antibiotics were administered. Crystalloid Administered: A 30 cc/kg IV fluid bolus was given. [If BMI >30, IBW is used. IBW calculated as 65kg.] (Example: For an IBW of 65kg, 30cc x 65kg = 1950cc). Alternative volume [insert volume] was given due to [insert reason]. Repeat Lactate Obtained: [Insert lactate value] Repeat Sepsis Exam Time: [Insert time] I have reassessed the patient’s hemodynamic status and tissue perfusion after the fluid bolus was given.

Critical Care Time Procedure Note Total time: [35 / 35-75 / 104] minutes separate from teaching time and exclusive of procedure time Impending deterioration: Airway / respiratory / cardiovascular / central nervous system / metabolic / renal Associated risk factors: Hypotension / shock / hypoxia / bleeding / trauma / dysrhythmia / metabolic changes / dehydration / acidosis / hypertension / drug or medication overdose Management: Bedside assessment and supervision of care Performed by: Myself Notes: Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration which required my direct attention, intervention, and personal management. Critical care time is exclusive of time spent on separately billable procedures. Time includes review of laboratory data, radiology results, discussion with consultants, and close monitoring for potential decompensation. It involved high complexity of medical decision-making to assess, manipulate, and support vital system functions to treat single or multiple organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition. Interventions were performed as documented.

Stroke Protocol Note The patient presents with symptoms concerning for an acute stroke. Initial Assessment: Last known well time: [Insert time] NIHSS Score: [Insert score] Head CT performed: [Normal / Abnormal] tPA Administration (if applicable): Eligibility determined: Yes / No tPA given at [Insert time], dose: [Insert dose] No contraindications present at time of administration Medications Administered: Aspirin: [Insert dose] / Antiplatelet therapy started Other [Insert medications] Consultation with Neurology: Neurology contacted and informed of patient’s condition Plan discussed: [Insert plan] Complications: None / [Insert complications] Patient Reassessment: BP [Insert], HR [Insert], Neurological status [Improved / Worsening] Patient to be admitted to ICU / Stroke unit for further management.

Acute Coronary Syndrome Protocol Note The patient presents with symptoms concerning for Acute Coronary Syndrome (ACS). Initial Workup: EKG performed: [Insert results] Troponin obtained: [Insert value] Chest X-ray: [Insert findings] Medications Administered: Aspirin: [Insert dose] Nitroglycerin: [Insert dose/route] Heparin: [Insert dose] Beta-blocker: [Insert name and dose] Statin: [Insert name and dose] Other [Insert medications] Consultation with Cardiology: Cardiology contacted and informed of patient’s condition Plan discussed: [Insert details] Complications: None / [Insert complications] Patient reassessed: BP [Insert], HR [Insert], Pain improved / Pain persists Patient to be admitted to ICU / Cardiac unit for further management and monitoring.

Respiratory Distress Management Protocol Note The patient presents with signs of respiratory distress. Initial Assessment: Respiratory Rate: [Insert value] Oxygen Saturation: [Insert value] Lung Sounds: Wheezing / Crackles / Normal Work of Breathing: Increased / Accessory muscle use / Retractions Interventions: Oxygen: Nasal cannula / Non-rebreather mask / CPAP / BiPAP Nebulizer treatment: Albuterol [Insert dose] / Ipratropium [Insert dose] Steroids: [Methylprednisolone / Prednisone], [Insert dose] Intubation (if necessary): Indication [Insert reason], Endotracheal tube size [Insert size] Reassessment: Post-treatment Respiratory Rate: [Insert value] Oxygen Saturation: [Insert value] Symptoms: Improved / Worsening Complications: None / Hypoxia / Respiratory failure / [Other] Disposition: Patient to be admitted to ICU for further respiratory support / Discharged with follow-up if improved.

Anaphylaxis Management Protocol Note The patient presents with symptoms consistent with anaphylaxis. Initial Assessment: Airway: Patent / Compromised Respiratory Status: Wheezing / Stridor / Normal BP: [Insert value] HR: [Insert value] Medications Administered: Epinephrine 0.3mg IM (Repeat dose if necessary) Antihistamine: [Diphenhydramine / Insert other], [Insert dose] Steroids: [Methylprednisolone / Prednisone], [Insert dose] Albuterol: [Insert dose] for bronchospasm IV Fluids: [Insert volume] mL of Normal saline for hypotension Reassessment: Respiratory Status: Improved / Unchanged BP: [Insert value] Symptoms: Resolved / Persistent Complications: None / [Insert complications] Disposition: Patient monitored for recurrent symptoms and admitted for observation / Discharged with EpiPen prescription and follow-up instructions.

Acute Heart Failure Management Protocol Note The patient presents with symptoms concerning for acute heart failure. Initial Assessment: BP: [Insert value] HR: [Insert value] Respiratory Rate: [Insert value] Oxygen Saturation: [Insert value] Lung Sounds: Crackles / Wheezing / Normal Extremities: Edema present / No edema Interventions: Diuretics: Furosemide [Insert dose] IV Nitroglycerin: [Insert dose] SL / IV for blood pressure control Oxygen: Nasal cannula / Non-rebreather / BiPAP Consider intubation if severe respiratory distress Reassessment: Post-treatment BP: [Insert value] Respiratory Rate: [Insert value] Oxygen Saturation: [Insert value] Lung Sounds: Improved / Persistent crackles Complications: None / Hypotension / Worsening respiratory distress / [Other] Disposition: Patient to be admitted to ICU for ongoing management / Discharged with follow-up instructions if improved.

Overdose/Poisoning Management Protocol Note The patient presents with signs of overdose/poisoning. Initial Assessment: Substance Ingested: [Insert substance] Time of Ingestion: [Insert time] Mental Status: Alert / Lethargic / Unresponsive BP: [Insert value] HR: [Insert value] Respiratory Rate: [Insert value] Oxygen Saturation: [Insert value] Interventions: Narcan (if opioid overdose): [Insert dose] IV/IM, response: [Improved / No improvement] Activated Charcoal (if indicated): [Insert dose] administered orally Benzodiazepine (if seizure): [Insert dose] IV Antidote (if specific poisoning): [Insert antidote] given IV Fluids: [Insert volume] mL Normal saline for hypotension EKG: [Insert findings] Labs: Toxicology screen, electrolytes, and ABG obtained Reassessment: Mental Status: Improved / No improvement BP: [Insert value] HR: [Insert value] Oxygen Saturation: [Insert value] Complications: None / Seizure / Respiratory failure / [Other] Disposition: Patient to be admitted to ICU for further monitoring / Discharged if stable.

Cardiac Arrest Protocol Note The patient presented in cardiac arrest. Initial Assessment: Rhythm: Asystole / PEA / VFib / VTach Time of Arrest: [Insert time] CPR initiated at: [Insert time] Defibrillation: [Insert #] shocks delivered at [Insert joules] IV/IO access obtained Medications Administered: Epinephrine: [Insert dose] given at [Insert time] Amiodarone: [Insert dose] given at [Insert time] Other: [Insert medications] Return of Spontaneous Circulation (ROSC): Yes / No Time of ROSC: [Insert time] Reassessment Post-ROSC: BP: [Insert value] HR: [Insert value] Oxygen Saturation: [Insert value] Mental Status: Alert / Unresponsive Post-arrest EKG: [Insert findings] Complications: None / Re-arrest / [Other] Disposition: Patient admitted to ICU for post-arrest care / Expired after [Insert #] rounds of ACLS protocol.

DKA Management Protocol Note The patient presents with symptoms concerning for diabetic ketoacidosis (DKA). Initial Assessment: Glucose: [Insert value] pH: [Insert value] Bicarbonate: [Insert value] Ketones: Positive / Negative Anion Gap: [Insert value] Potassium: [Insert value] Interventions: IV Fluids: Normal saline bolus of [Insert volume] mL Insulin: Regular insulin bolus [Insert dose] units IV, followed by infusion at [Insert rate] units/hour Potassium replacement: [Insert dose] (if K

Postmortem Care and Documentation Note Time of death: [Insert time] Confirmed correct: Patient identity, time, date Pronounced by: Myself / [Other provider] Family notified: Yes / No Cause of death documented: [Insert cause] Medical examiner notified: Yes / No Autopsy requested: Yes / No / Declined by family Death certificate completed: Yes / No / Pending Postmortem care: Lines and tubes removed: Yes / No Body prepared for transport to morgue / funeral home Personal belongings: Secured and given to family / Transported with the body Organ donation discussed: Yes / No / N/A Complications: None Performed by: Myself Total time: [Insert minutes]

DNR Discussion and Documentation Note Time: [Insert time] Confirmed correct: Patient, family, time, date Discussion held with: Patient / Family / Legal guardian Indication for DNR: Terminal illness / Poor prognosis / Patient request DNR status confirmed: Yes / No Specifics of DNR: No CPR / No intubation / No defibrillation / Other Family understanding: Full / Partial / Further clarification needed Decision support: Palliative care team involved / Social worker involved / [Other] Complications: None DNR documentation completed and signed: Yes / No Performed by: Myself Total time: [Insert minutes]

Withholding/Withdrawal of Care Note Time: [Insert time] Confirmed correct: Patient, family, time, date Discussion held with: Patient / Family / Legal guardian Indication for withholding/withdrawal of care: Terminal illness / Poor prognosis / Patient request / Other Details of care withheld/withdrawn: Mechanical ventilation / CPR / Pressors / Feeding tubes / Other Family understanding: Full / Partial / Further clarification needed Decision support: Palliative care team involved / Social worker involved / [Other] Complications: None Documentation completed: Yes / No Performed by: Myself Total time: [Insert minutes]

Clinical Decision Calculators

HEART Score

The HEART score helps assess the risk of major adverse cardiac events (MACE) in patients presenting with chest pain. It guides decision-making regarding admission or discharge.

Link to MDCalc HEART Score

Link to MDCalc HEART Pathway

HEART Score is a standalone tool focused on providing an immediate risk assessment based on a single set of variables.

HEART Pathway takes it a step further by incorporating serial troponin testing to guide further decision-making, especially in low-risk patients, and reduce unnecessary admissions and diagnostic testing.