Indication: Respiratory Distress
A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a flat position. Sedation was obtained using <Versed 3mg>, and additionally with <Etomidate 20mg>. The patient was easily ventilated using an ambu bag. The <GLIDESCOPE TECHNOLOGY/ MAC 3 BLADE> was used and inserted into the oropharynx at which time there was a Grade 1 view of the vocal cords. A 7.5-french endotracheal tube was inserted and visualized going through the vocal cords. The stylette was removed. Colorimetric change was visualized on the CO2 meter. Breath sounds were heard in both lung fields equally. The endotracheal tube was placed at 23 cm, measured at the teeth. <Attending/Resident> was present for the entire procedure.
A chest x-ray was ordered to assess for pneumothorax and verify endotrachealtube placement.
Estimated Blood Loss: <____>
The patient tolerated the procedure well and there were no complications.
Other procedure note examples:
- Endotracheal Intubation
- Central Line (CVC) Access
- Arterial Line
- Lumbar Puncture
- Thoracostomy (Chest Tube)
- Swan-Ganz Catheter Placement
Also, thank you to my two favorite websites for helping me write notes in the hospital: