Procedure Notes: Thoracostomy (Chest Tube)

THORACOSTOMY (CHEST TUBE) PLACEMENT

Date: <____>
Time: <____>
Indication: Pneumothorax/Hemothorax
Resident: <____>
Attending: <____>

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was positioned appropriately for chest tube placement. The patient’s <right/left> chest was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the surrounding skin area. A <2 cm> skin incision was made in the mid-axillary line at the inframammarycrease. Utilizing blunt dissection a subcutaneous tunnel was created cephalad just adjacent to the superior rib. The pleural space was entered bluntly and gush of  <air/blood> was observed. A finger was inserted into the pleural space to check for anatomy and guide tube insertion. A <36F/40F> thoracostomy tube was inserted using a Kelly clamp and positioned appropriately. The chest tube was sutured securely to the skin and a sterile dressing applied. A pleurevac was attached to the chest tube and a chest x-ray obtained. <Attending/Resident> was present for the entire procedure.

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
• Thoracentesis
• Thoracostomy (Chest Tube)
• Swan-Ganz Catheter Placement

Also, thank you to my two favorite websites for helping me write notes in the hospital:

• University of Michigan Procedure Note Templates
• Swimed.org Templates

Related posts:

Procedure Notes: Central Venous Catheter (CVC) Placement Procedure Notes: Thoracentesis Procedure Notes: Lumbar Puncture