Procedure notes are quite important for quality care and treatment. The format of procedure notes is discussed here
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Things to Consider While Preparing
Procedure Notes
The aim of the procedure note or clinical note is to
document why and how a medical procedure was done
when it was performed and the patient!s response to the
procedure" #rocedure notes typically detail a procedure
performed in a physician$s office at a hospital %edside or
in a specialty clinic" These notes can %e used for a wide
variety of procedures such as a %iopsy done at a
dermatolo&y clinic orotracheal intu%ation done in the
emer&ency room '()* or the removal of se%aceous cysts in
a family practice"
+et$s see what should %e included in the reports when
transcri%in& them"
Components of a Procedure Note
,n some cases clinical notes simply name the procedure
and &ive a %rief summary alon& with the pertinent findin&s"
,n other situations clinical notes are precisely formatted
and have procedure-specific su%headin&s" ,n %oth cases the
first thin& is to identify the procedure performed as
follows-
#)./(01)( #()2.)M(0
- Triple lumen catheter 'T+/* placement
The other components of these notes are as follows-
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• Indications – The %ody of procedure note starts with
the e3planation of why the procedure mentioned is
%ein& performed"
,40,/5T,.4S 2.) #)./(01)(
- This is a 70 year old male who needs ,6 access"
5lternative names of this section are- 7#reoperative
0ia&nosis$ and 7)eason for #rocedure or 8istory$ 'when
more detail is included*"
• Medications – 5 list of patient$s current medication is
included and needs to %e num%ered and listed
vertically in the transcript of the procedure note 'an
e3ample shown %elow*" Suppose a colonoscopy is
performed on a patient and the current medications are
5m%ien and #lavi3 which should %e transcri%ed as
follows-
/1))(4T M(0,/5T,.4S
1" 5m%ien"
2" #lavi3"
There is no need to num%er vertically listed anesthesia or
procedure-related medications unless specified %y the
healthcare facility" Such medications may %e transcri%ed as-
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#)(M(0,/5T,.4S
6ersed 9 m& 0emerol 79 m& ,6"
• Description of Procedure – This section provides a
narrative description of the procedure under the titles
such as #)./(01)( ,4 0(T5,+ #)./(01)(
S1MM5): or T(/84,;1(" ,f a particular
procedure includes measurements as part of the
process these are also lin<ed to the narrative"
• Findings and Recommendations – ,f postoperative
dia&noses is not stated at the %e&innin& of the report or
%undled into the procedure description the results of
the dia&nostic study should %e listed vertically with
num%er under the section titled 2indin&s /onclusion
or ,mpression alon& with )ecommendations 'listed
hori=ontally separated %y comma* if any"
Importance of Accurate Procedure Notes
• #rocedure notes provide the complete picture of how a
patient is doin& medically which helps the physician
understand the patient$s case so that the condition can
%e dia&nosed and treated" (rror-free procedure notes
are necessary to identify complications and provide
appropriate treatment"
• 5ccurate procedural documentation is essential for
medical coders to assi&n appropriate /#T codes so
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that the physicians can receive proper and timely
reim%ursement for services rendered"
• ,f they are curious a%out somethin& patients do have
the ri&ht to loo< at their medical chart and consult
their physician a%out the same" They can also petition
to correct inaccuracies in their charts" 5ccurate
procedure notes clearly and concisely record relevant
data a%out medical procedures and can protect medical
practices from le&al conse>uences"
,n most cases physicians find it difficult to document
procedure notes and focus on their core tas< of patient care
at the same time" That$s why most rely on experienced
medical transcriptionists for the transcription of their
clinical notes in correct format and send %ac< to the
physicians"