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1. Consent Procedure
CONSENT:
[_] During the informed consent discussion regarding the procedure, or treatment, I explained the following
to the patient/designee:
a. Nature of the procedure or treatment and who will perform the procedure or treatment.
b. Necessity for procedure and the possible benefits.
c. Risks and complications (most common and serious).
d. Alternative treatments and the risks, benefits and side effects of each (including no treatment).
e. Likelihood of the patient achieving his/her goals without this procedure and surgery treatment.
f. Problems that might occur during the recuperation.
g. Conflicts of interest, if any
[_] The procedure was emergent, the patient was unable to provide consent, and a designee was not
immediately available.
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.

2. 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.
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.
Lumbar Puncture
Date: <____>
Time: <____>
Indication: Altered Mental Status
Resident: <____>
Attending: <____>

3. 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.
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.
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.

4. 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.
ROS
Subjective
Patient ID: Manique Huston is a 47 y.o. female.
HPI
Review of Systems
Constitutional: Negative for activity change, appetite change, chills, diaphoresis, fatigue,
fever and unexpected weight change.
HENT: Negative for congestion, dental problem, drooling, ear discharge, ear pain, facial
swelling, hearing loss, mouth sores, nosebleeds, postnasal drip, rhinorrhea, sinus
pressure, sinus pain, sneezing, sore throat, tinnitus, trouble swallowing and voice
change.
Eyes: Negative for photophobia, pain, discharge, redness, itching and visual
disturbance.
Respiratory: Negative for apnea, cough, choking, chest tightness, shortness of breath,
wheezing and stridor.
Cardiovascular: Negative for chest pain, palpitations and leg swelling.
Gastrointestinal: Negative for abdominal distention, abdominal pain, anal bleeding,
blood in stool, constipation, diarrhea, nausea, rectal pain and vomiting.

5. Endocrine: Negative for cold intolerance, heat intolerance, polydipsia, polyphagia and
polyuria.
Genitourinary: Negative for decreased urine volume, difficulty urinating, dyspareunia,
dysuria, enuresis, flank pain, frequency, genital sores, hematuria, menstrual problem,
pelvic pain, urgency, vaginal bleeding, vaginal discharge and vaginal pain.
Musculoskeletal: Negative for arthralgias, back pain, gait problem, joint swelling,
myalgias, neck pain and neck stiffness.
Skin: Negative for color change, pallor, rash and wound.
Allergic/Immunologic: Negative for environmental allergies, food allergies and
immunocompromised state.
Neurological: Negative for dizziness, tremors, seizures, syncope, facial asymmetry,
speech difficulty, weakness, light-headedness, numbness and headaches.
Hematological: Negative for adenopathy. Does not bruise/bleed easily.
Psychiatric/Behavioral: Negative for agitation, behavioral problems, confusion,
decreased concentration, dysphoric mood, hallucinations, self-injury, sleep disturbance
and suicidal ideas. The patient is not nervous/anxious and is not hyperactive.
Objective
Physical Exam
Objective
Physical Exam
Vitals reviewed. Exam conducted with a chaperone present.
Constitutional:
General: She is not in acute distress.
Appearance: Normal appearance. She is obese. She is not ill-appearing, toxic-
appearing or diaphoretic.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: Tympanic membrane, ear canal and external ear normal. There is no
impacted cerumen.
Left Ear: Tympanic membrane, ear canal and external ear normal. There is no
impacted cerumen.
Nose: Nose normal. No congestion or rhinorrhea.
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: Oropharynx is clear. No oropharyngeal exudate or posterior oropharyngeal
erythema.

6. Eyes:
General: No scleral icterus.
Right eye: No discharge.
Left eye: No discharge.
Extraocular Movements: Extraocular movements intact.
Conjunctiva/sclera: Conjunctivae normal.
Pupils: Pupils are equal, round, and reactive to light.
Neck:
Vascular: No carotid bruit.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Pulses: Normal pulses.
Heart sounds: Normal heart sounds. No murmur heard.
No friction rub. No gallop.
Pulmonary:
Effort: Pulmonary effort is normal. No respiratory distress.
Breath sounds: Normal breath sounds. No stridor. No wheezing, rhonchi or rales.
Chest:
Chest wall: No tenderness.
Abdominal:
General: Abdomen is flat. Bowel sounds are normal. There is no distension.
Palpations: Abdomen is soft. There is no mass.
Tenderness: There is no abdominal tenderness. There is no right CVA tenderness, left
CVA tenderness, guarding or rebound.
Hernia: No hernia is present.
Genitourinary:
General: Normal vulva.
Vagina: No vaginal discharge.
Rectum: Normal. Guaiac result negative.
Musculoskeletal:
General: No swelling, tenderness, deformity or signs of injury. Normal range of motion.
Cervical back: Normal range of motion and neck supple. No rigidity or tenderness.
Right lower leg: No edema.
Left lower leg: No edema.
Lymphadenopathy:
Cervical: No cervical adenopathy.
Skin:
General: Skin is warm and dry.
Capillary Refill: Capillary refill takes less than 2 seconds.
Coloration: Skin is not jaundiced or pale.
Findings: No bruising, erythema, lesion or rash.

7. Neurological:
General: No focal deficit present.
Mental Status: She is alert and oriented to person, place, and time. Mental status is at
baseline.
Cranial Nerves: No cranial nerve deficit.
Sensory: No sensory deficit.
Motor: No weakness.
Coordination: Coordination normal.
Psychiatric:
Mood and Affect: Mood normal.
Behavior: Behavior norm
Assessment/Plan: