PROCEDURE: The official name of the procedure, not an abbreviation of it. Central venous catheter, not "central line" or "TLC".
INDICATION: meningitis, pleural effusion, ascites, acute renal failure, sepsis, cardiac arrest, etc.
PHYSICIAN(S): The name of the attending and all residents in a list.
CONSENT: Procedure, benefits, risks (include those of bleeding, infection, injury, pneumothorax, stroke, death, organ dysfunction, and anesthesia), and alternatives explained to the patient (and their family members) who voiced understanding of the information and agreed to proceed with the (spinal tap, thoracentesis, paracentesis, central venous catheter placement, etc.) Consent signed and on chart (if so).
DESCRIPTION: Area prepped and draped in a sterile fashion. (Local, spinal, etc.) anesthetic administered with (cc medication). Describe technique including instruments, body location, occurrences, etc. This should be the longest section of all. Go detail by detail.
COMPLICATIONS: Pneumothorax, etc. or None.
ESTIMATED BLOOD LOSS: amount in mL. or None.
DISPOSITION: The patient is alert and oriented, and resting comfortably, breathing nonlabored; extremities neurovascularly intact; incision clean, dry and intact; etc. Patient is clinically and hemodynamically stable after the procedure with no change in vital signs nor mentation, and tolerated the procedure well.
Progress (SOAP) Note
Cardiology Progress Note and Consult
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