Monthly Archive: January 2012

Internet based paging system

howstuffworks.com

If you need to send numeric or text pages to medical students, residents, or attendings Telepage Web Pager is the best website. Most hospitals have a built in method to text page anyone with a hospital affiliation. However, this web based paging system allows you to page anything you want to any pager in the country.  Try it, it’s free!

http://www.telepagewebpager.us/

Procedure Notes: Central Venous Catheter (CVC) Placement

Central Venous Catheter (CVC, Central Line) Placement

Date: <____>
Time: <____>
Indication: Hemodynamic monitoring/Intravenous access
Resident: <____>
Attending: <____>

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a dependent position appropriate for central line placement based on the vein to be cannulated. The patient’s <right/left> < neck/shoulder/groin> was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the surrounding skin area. A triple lumen <9-French> Cordis catheter was introduced into the the <subclavian/internal jugular/common femoral vein> using the Seldinger technique <and under ultrasound guidance>. The catheter was threaded smoothly over the guide wire and appropriate blood return was obtained. Each lumen of the catheter was evacuated of air and flushed with sterile saline. The catheter was then sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate. <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:

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

Procedure Notes: Lumbar Puncture

Lumbar Puncture

Date: <____>
Time: <____>
Indication: Altered Mental Status
Resident: <____>
Attending: <____>

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in the <LEFT/RIGHT> lateral decubitus position in a semi-fetal position with help from the nursing staff. The area was cleansed and draped in usual sterile fashion. 1% lidocaine was used anesthetize the surrounding skin area. A <20-gauge 3.5-inch> spinal needle was placed in the <L3-L4/L4-L5> interspace. Clear cerebral spinal fluid was obtained and the opening pressure was noted to be <?cm>. Four tubes were filled with 4 mL of CSF. These were sent for the usual tests, including 1 tube to be held for further analysis if needed. <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:

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

Procedure Notes: Thoracentesis

Thoracentesis

Date: <____>
Time: <____>
Indication: Large pleural effusion
Resident: <____>
Attending: <____>

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:

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

Procedure Notes: Swan-Ganz Catheter

Swan-Ganz Catheter Placement

Date: <____>
Time: <____>
Indication: Hemodynamic monitoring/Intravenous access
Resident: <____>
Attending: <____>

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a dependent position appropriate for central line placement based on the vein already cannulated with a 9F Cordis catheter. The patient’s <right/left>  <shoulder/neck/groin> was prepped and draped in sterile fashion. A triple lumen continuous cardiac output Swan-Ganz catheter was brought onto the field and each line flushed with sterile saline and the SVO2 sensor calibrated. The catheter was introduced into the Cordis catheter to a distance of 15-17 cm. The balloon was then inflated and the catheter was advanced through the right ventricle and into the pulmonary artery until a wedge position pressure tracing was obtained. The balloon was then deflated and verification of return of a pulmonary artery pressure tracing made. During the floating procedure to position the catheter the position of the catheter tip was determined by continuous pressure monitoring via the distal port. The catheter was locked to the Cordis with the tip inserted to a distance of <?cm> and a sterile dressing applied. <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:

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

Procedure Notes: Endotracheal Intubation

Endotracheal Intubation

Date: <____>
Time: <____>
Indication: Respiratory Distress
Resident: <____>
Attending: <____>

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:

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

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:

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

Procedure Notes: Arterial Line

ARTERIAL LINE (A-Line) PLACEMENT

Date: <____>
Time: <____>
Indication: Hemodynamic monitoring
Resident: <____>
Attending: <____>

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. Allen’s test was performed to ensure adequate perfusion. The patient’s <right/left> wrist was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the area. A <18G/20G> Arrow arterial line was introduced into the <radial/femoral> artery. The catheter was threaded over the guide wire and the needle was removed with appropriate pulsatile blood return. The catheter was then sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate. <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:

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