Procedure notes

A procedure note proves the right thing was done to the right patient, with consent, safely. Templates capture the mechanics and skip the parts that defend you.

01The skeleton

• Indication — why this, now.
• Consent — obtained, or the emergency exception that applied.
• Time-out — correct patient, site, procedure.
• Technique — what you did, reproducibly.
• Findings — what you found; specimens sent.
• Complications — present, or explicitly none.
• Who performed and who supervised.

02Consent is one sentence

03The three people skip

• The time-out. One line. For anything with a side, name it: “left” chest tube.
• Complications. Write “no immediate complications” even when there are none. When there’s a complication, document it honestly and now — not in hindsight.
• Supervision. If a resident or APP did it, write what actually happened. An attestation that claims more than occurred is worse than none.

Educational only. Synthetic examples. Not medical or legal advice. Follow local policy for consent, sedation, and supervision.