Procedure Note
The note that protects you. Write it immediately, while you still remember the details.
The official name of the procedure, not an abbreviation of it. Central venous catheter, not "central line" or "TLC."
Meningitis, pleural effusion, ascites, acute renal failure, sepsis, cardiac arrest.
The name of the attending and all residents, in a list.
Procedure, benefits, risks (include 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, or whatever it is. Consent signed and on the chart, if so.
Area prepped and draped in a sterile fashion. Local or spinal anesthetic administered, with the agent and the amount. Then describe the technique, including instruments, body location, and everything that happened. This should be the longest section of all. Go detail by detail.
Pneumothorax and so on, or none.
Amount in mL, or none.
The patient is alert and oriented, resting comfortably, breathing non-labored; extremities neurovascularly intact; incision clean, dry and intact. The patient is clinically and hemodynamically stable after the procedure with no change in vital signs or mentation, and tolerated the procedure well.
If the procedure requires imaging confirmation, a post-procedure chest x-ray after a central line for example, write down that you ordered it and what it showed. A note that ends before the confirmation is the note that gets read aloud in a deposition.