Proc Note

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Above note reviewed.

SUBJECTIVE

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Patient seen in the clinic.  Pertinent subjective elements recorded in A/P below.  10 point ROS completed, all negative except as indicated in A/P.

 OBJECTIVE

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 The following exam was performed, pertinent positive and negative findings are documented below in the A/P section.

 Vitals reviewed.  

 General appearance assessed.

 Neurologic gross assessed.

 HEENT assessed.

 Cardiovascular perfusion assessed.

 Respiratory status and effort assessed.

 Abdomen and Back visualized.

 Extremities assessed.

 PROCEDURE NOTE

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 PRE-PROCEDURE COUNSELING & CONSENT:

 Possible limitations and risks include pain, bleeding, infection, complications from anesthesia, partial success requiring repetition of procedure.  Verified the signed consent form is in the chart.  Peri-operative risks, benefits, and limitations discussed and understood - Patient wished to proceed.

 TIME OUT:  see A/P below for time of time-out

   YES- Patient was identified using full name plus any suffix and DOB.

   YES- Patient was evaluated and medical record reviewed to include medical history and laboratory findings, if ordered.

   N/A- Radiographs are properly oriented and correct laterality has been visually confirmed.

   YES- Procedure and site/side matches the consent form.

   YES- Patient/Legal Guardian was involved in the site/side marking.

   YES- Final Time Out - Physician paused (if alone) or verbally confirmed with the procedure team that this is the correct patient, procedure and site/side (if applicable).  The patient has been positioned correctly for the procedure.  All necessary equipment and implants are available.

(= ALLERGIES =)

 - {}NKDA

(= CURRENT MEDICATIONS =)

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███ OBJECTIVE ███

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███ ASSESSMENT & PLAN ███

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