Smart Phrases And Workups – Procedures

Arterial LIne
Arterial Line Procedure Note

Date of Service: @TD@
Pre-Procedure Diagnosis: @PRINCIPALPROBLEM@
Post-Procedure Diagnosis: @PRINCIPALPROBLEM@
Attending Physician: ***
Performing Physician: Drew Sheldon, MD
Supervising Physician(s): ***

Patient Summary: @NAME@ is a @AGE@ @SEX@ who was admitted to the ICU for @PRINCIPALPROBLEM@

Indications:
- Continuous and reliable hemodynamic monitoring
- To allow for accurate titration of supportive medications such as vasopressors and/or ionotropes
- Access to arterial circulation for arterial blood gas sampling as well as frequent blood sampling if needed

Consent: Detailed explanation of the procedure, treatment options, risks - including but not limited to pain, infection, and bleeding - benefits, and alternatives were explained to the patient and/or family member(s) and/or patient surrogate. Informed consent was documented, signed, and obtained.

Technique: A time out was performed identifying the patient, the correct procedure, and the correct location with the nursing staff. The appropriate artery was identified and confirmed with bedside ultrasound prior to field sterilization. The *** right *** left *** wrist ***groin was prepped with 2% chlorhexidine and draped with sterile towels in the usual fashion. Using sterile technique, the ultrasound transducer was used to identify the appropriate artery. *** 1% lidocaine was administered subcutaneously to the procedure area for local anesthesia. The *** radial *** femoral artery was then cannulated with a *** 20 *** 22 gauge catheter. The area was cleaned, and the catheter was sutured in place. A sterile dressing was applied over the site prior to removal of drapes. The patient tolerated the procedure *** well, and there were *** no complications.

EBL: *** minimal, < 5mL
Complications: None

Danielle Brazel, MD
Internal Medicine, PGY-1
@TD@
@NOW@
Central Line
Central Venous Catheter Procedure Note

Date of Service: @TD@
Approximate Time of Procedure: ***
Attending Physician: ***
Performing Physician: Drew Sheldon, MD
Supervising Physician: ***

Patient Summary: @NAME@ is a @AGE@ @SEX@ who was admitted to the ICU for @PRINCIPALPROBLEM@

Indication: Hemodynamic monitoring and Intravenous access ***Hemodialysis

Consent: Detailed explanation of the procedure, treatment options, risks - including but not limited to pain, infection, and bleeding - benefits, and alternatives were explained to the patient and/or family member(s) and/or patient surrogate. Informed consent was documented, signed, and obtained.

Procedure Summary:
Prior to initiation of the procedure, a bedside ultrasound was used to locate an optimal access site in the *** right *** left *** neck *** chest *** groin. Subsequently a time-out was performed identifying the patient, the correct procedure, and the correct location with the nursing staff. I performed appropriate hygiene measures prior to the procedure and then donned personal protective equipment including *** a surgical cap, mask *** with protective eyewear, a sterile gown, and sterile gloves throughout the procedure. The ***right ***left ***neck ***chest ***groin was cleansed and draped in usual sterile fashion using a chlorhexidine scrub. Anesthesia was achieved with 1% lidocaine in order to provide paresthesia to the skin and soft tissue. The *** right *** left *** internal jugular *** subclavian *** femoral vein was accessed under ultrasound guidance with an 18 gauge thin wall needle. A *** triple lumen *** double lumen *** cordis *** Mahurkar catheter was inserted via the seldinger technique. Blood was withdrawn from all lumens and flushed with normal saline. The catheter was sutured in place, and a sterile dressing was applied over the site prior to removal of drapes. The patient tolerated the procedure well and there were no immediate complications.

EBL: ***
Complications: ***

Chest X-ray is pending at this time.

Danielle Brazel, MD
@TD@ @NOW@
Intubation	
Intubation Procedure Note

Date of Service: @TD@
Approximate Time of Procedure: ***
Attending Physician: ***
Performing Physician: Drew Sheldon, MD
Supervising Physician: ***

Patient Summary: @NAME@ is a @AGE@ @SEX@ who was admitted to the ICU for @PRINCIPALPROBLEM@

Indication: *** Inability to protect airway *** Acute Respiratory Failure *** Hypoxemia

Consent: *** Detailed explanation of the procedure, treatment options, risks - including but not limited to pain, infection, and bleeding - benefits, and alternatives were explained to the patient and/or family member(s) and/or patient surrogate. Informed consent was documented, signed, and obtained.

*** Due to the emergent nature of the procedure and concern for airway loss, consent  was implied and was not formally obtained or documented prior to the procedure.

Procedure Summary: Prior to intubation, the patient was preoxygenated to SpO2 of *** 100% via bag valve mask. Patient was subsequently sedated with *** mg of etomidate *** propofol and paralyzed with *** mg of *** succinylcholine *** rocuronium. Once the patient was adequately sedated *** and paralyzed, intubation was attempted *** time(s) using a *** 4.0 *** Mac blade *** direct laryngoscope *** GlideScope with a *** 7.0mm *** 7.5mm *** 8.0mm cuffed endotracheal tube *** while cricoid pressure was applied. A grade ***1 ***2 ***3 ***4 of the vocal cords were visualized and the ETT passed through the vocal cords atraumatically. Bilateral chest rise was observed, bilateral breath sounds were auscultated, and color change was observed with colorimetric end-tidal CO2 detector to confirm placement. The cuff was then inflated and the end of the ETT was then connected to the mechanical ventilator. ETT was secured with adhesive tape ***cm at the teeth.

Complications: *** No immediate complications were noted.

Chest X-ray is pending at this time.

Danielle Brazel, MD
Internal Medicine, PGY-1
@TD@ @NOW@
LP	
Lumbar Puncture Procedure Note

Date of Service: @TD@
Approximate Time of Procedure: ***
Attending Physician: ***
Performing Physician: Drew Sheldon, MD
Supervising Physician: ***

Patient Summary: @NAME@ is a @AGE@ @SEX@ admitted for @PRINCIPALPROBLEM@

Indication: ***Acute encephalopathy ***Assess for CNS infection ***Assess for CNS malignancy ***Assess for subarachnoid hemorrhage

Consent: Detailed explanation of the procedure, treatment options, risks - including but not limited to pain, infection, and bleeding - benefits, and alternatives were explained to the patient and/or family member(s) and/or patient surrogate. Informed consent was documented, signed, and obtained.

Procedure Summary:
A time-out was completed verifying the 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. The puncture location was then determined using anatomic landmarks ***and ultrasound guidance. The area was then 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 intervertebral space. ***Clear cerebral spinal fluid was obtained after removal of the stylet, and the opening pressure was noted to be ***cm. ***Four 8mL sample tubes were then filled with a total of ***mL of CSF. These were sent for the usual tests, including 1 tube to be held for further analysis if needed. The patient tolerated the procedure ***well, and there were ***no immediate complications. The patient was counseled to lie flat for at least 1 hour after the procedure to avoid post-LP headache.

EBL: *** <1mL
Complications: ***

Danielle Brazel, MD
Internal Medicine, PGY-2
@TD@ @NOW@
PARA	
Paracentesis Procedure Note

Date of Service: @TD@
Approximate Time of Procedure: ***
Attending Physician: ***
Performing Physician: Drew Sheldon, MD
Supervising Physician: ***

Patient Summary: @NAME@ is a @AGE@ @SEX@ who was admitted for @PRINCIPALPROBLEM@

Indication:
Diagnostic: To evaluate the patient's ascitic fluid for *** protein, albumin, cell count, Gram stain, culturing, cytology, glucose, LDH, and qualitative assessment.
Therapeutic: To relieve abdominal distension, improve respiratory mechanics, and increase the patient's comfort.

Consent: Detailed explanation of the procedure, treatment options, risks - including but not limited to pain, infection, and bleeding - benefits, and alternatives were explained to the patient and/or family member(s) and/or patient surrogate. Informed consent was documented, signed, and obtained.

Procedure Summary:
Prior to initiation of procedure, bedside ultrasound was used to locate an optimal fluid pocket in the abdomen. Subsequently a time-out was performed identifying the patient, the correct procedure, and the correct location with the nursing staff. I performed appropriate hygiene measures prior to the procedure and then donned personal protective equipment including *** a surgical cap, mask with protective eyewear, a sterile gown, and sterile gloves throughout the procedure. The *** of the abdomen was cleansed and draped in usual sterile fashion using a chlorhexidine scrub. Anesthesia was achieved with 1% lidocaine in order to provide paresthesia to the skin, soft tissue, and peritoneum. The paracentesis catheter was then inserted and advanced with negative pressure until *** colored fluid was aspirated. Approximately *** 60 mL of ascitic fluid was collected and sent for laboratory analysis. The catheter was then connected to the vaccutainer and *** Liters of additional ascitic fluid were drained. The catheter was removed and *** leaking was noted. A wound bandage was placed over the puncture site. The patient tolerated the procedure well without any immediate complications. Estimated blood loss was *** minimal.

Ascitic Fluid Drained: ***
EBL: *** minimal
Complications: None

The following labs were sent:
- serum and ascitic protein
- serum and ascitic albumin
- cell count with diff
- Gram stain
- aerobic and anerobic cultures
- cytology
- ascitic glucose
- ascitic LDH

Danielle Brazel, MD
Internal Medicine, PGY-1
@TD@ @NOW@