Indication: Large pleural effusion
A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient’s <right/left> side was prepped and draped in a sterile manner after the appropriate infiltration level was confirmed by ultrasound. 1% lidocaine was used anesthetize the surrounding skin. A finder needle was then used to locate fluid and clear yellow fluid was obtained. A 10-blade scalpel used to make the incision. The thoracentesis catheter was then threaded without difficulty. The patient had <?mL> of clear yellow fluid removed. <Attending/Resident> was present for the entire procedure. A post-procedure chest x-ray was ordered and the fluid will be sent for several studies.
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: