Procedure Note - Restraint Note(s)

Initial Restraint Note:

Patient felt to meet indications for [chemical/physical/chemical and physical restraint] due to concern that the patient presents an imminent threat to themselves and staff.  Attempts at de-escalation [were unsuccessful/could not be attempted due to agitation and violent behavior].  We considered risks of the use of [chemical/physical] restraints, and felt that the benefits of harm reduction outweighed these risks at this time.

Chemical restraint was initiated with [antipsychotic-Haloperidol (Haldol) ## mg IM/IV/Olanzapine (Zyprexa) ## mg PO/IM/IV/Ziprasidone (Geodon) ## mg IM and benzodiazepine-Lorazepam (Ativan) ## mg IM/IV/Midazolam (Versed) ## mg IM/IV].

Physical restraints were felt to be necessary due to [continued agitation despite use of chemical restraints for rapid tranquilization/due to continued agitation while awaiting maximal effects of chemical restraint/inability to safely administer chemical restraints due to agitation and aggressive behavior].

I personally evaluated the patient before and after restraint placement [along with my attending/resident Dr. NAME] as documented in the history and physical exam section.  We discussed plan for nursing to reassess the patient every [10-15] minutes, and will plan to repeat our exam within 1 hour with the goal of potentially discontinuing some or all of the applied physical restraints.

Continued Restraint Note

Patient felt to still meet indications for physical restraint at this time due to concern that the patient still presents an imminent threat to themselves and staff.  We again made unsuccessful attempts at de-escalation which [were unsuccessful/still could not be attempted due to agitation and violent behavior].  We considered risks of the continued use of physical restraints, and felt that the benefits of harm reduction outweighed these risks at this time.

I personally evaluated the patient before and after restraint placement [along with my attending/resident Dr. NAME] as documented in the history and physical exam section.  We discussed plan for nursing to reassess the patient every [10-15] minutes, and will plan to repeat our exam within 1 hour with the goal of potentially discontinuing some or all of the applied physical restraints.

Discontinuing Restraint Note

Patient felt to no longer meet indications for physical restraint at this time with plan [to discontinue all restraints at this time/to transition from 4-point to 2-point and ultimately discontinue all restraints if patient remains calm and cooperative].  Patient noted to have no evidence of complications from restraint use, such as significant soft tissue injuries or rhabdomyolysis among others.

I personally evaluated the patient before and after restraint placement [along with my attending/resident Dr. NAME] as documented in the history and physical exam section.

Note: Laws regarding the use of restraints vary by state and hospital, so you should be aware of the specific requirements at your institution.  These should all be time-stamped and signed for legal purposes.  It is absolutely essential that you re-evaluate any patient you place into physical restraints frequently with the goal of always using the least restrictive method to control the agitated patient.

https://ercast.libsyn.com/art-of-the-chemical-takedown
http://www.emdocs.net/agitation/

Procedure Note - Greater Occipital Nerve (GON) Block

Greater Occipital Nerve (GON) Block Note:

The patient was counseled on the risks, benefits, and alternatives to the procedure, and provided [written/verbal] consent.  A timeout procedure was performed prior to initiating the procedure. 

The patient was placed in a seated and the approximate location of the greater occipital nerve (GON) was identified based on landmarks (the index finger was placed on the occipital protuberance with the thumb placed on the mastoid process (either side)-measured 1/3 the distance from the occipital protuberance as the likely location of the GON).  The area was cleaned appropriately using [alcohol/chlorhexadine/betadine].  Using a 23-gauge needle [3-5 mL of 1/2% lidocaine/2-4 mL of 0.25/0.5% bupivicaine] was infiltrated at the site of the GON using a 'fanning technique' (1 mL of anesthetic injected immediately adjacent to GON, 1 mL medial to the GON, and 1 mL lateral to the GON for maximal infiltration (may be repeated bilaterally)).

The patient was monitored following the procedures and reported [moderate/significant] relief in pain.  The patient tolerated the procedure well without complications.

http://www.emdocs.net/pain-profiles-ed-migraine-management-the-new-kid-on-the-block/

Procedure Note - Sphenopalantine Ganglion (SPG) Block

Sphenopalantine Ganglion (SPG) Block Note:

The patient was counseled on the risks, benefits, and alternatives to the procedure, and provided [written/verbal] consent.  We specifically discussed risk of a bitter taste from the anesthetic, nausea, trauma resulting in epistaxis, lightheadedness, and numbness in the posterior pharynx among others.  A timeout procedure was performed prior to initiating the procedure. 

The patient was placed in a supine position with the head tilted into a 'sniffing' position.  The patient was placed on a cardiac monitor (because of administration of anesthetic in a highly vascular area).  The nasal passage was anesthesized with 1 mL of 1% lidocaine per nostril aerosolized using an atomizer.  A cotton-tip applicator was soaked in [1/2]% lidocaine and advanced along the superior border of the middle turbinate of each nostril until the tip contacts the mucosa overlying the sphenopalantine galglion (SPG).

The applicators were left in place [for 10 minutes/until the patient felt relief], and were then gently removed.  The patient tolerated the procedure well without complications.

https://www.aliem.com/trick-sphenopalatine-ganglion-block-primary-headaches/

Procedure Note - Priapism Aspiration

Priapism Aspiration Note:

The patient was counseled on the risks, benefits, and alternatives to the procedure, and provided [written/verbal] consent.  A timeout procedure was performed prior to initiating the procedure. 

The penis was prepped and draped in the usual sterile manner.  A penile block was performed by injecting [##] mL of lidocaine [at the 2 and 10 o'clock positions at the dorsal aspect of the base of the penis/in a complete ring around the base of the penis].  An [18/##] gauge needle was inserted into the penile shaft at the 2 and 10 o'clock positions to aspirate [20-30 mL of blood from the right/left side/each side].  Patient noted to have [some/mild/moderate/significant] improvement in priapism after aspiration.

A diluted solution of Phenylephrine was injected into the base of the penis after confirming needle was in the corpus cavernosum by aspirating blood.  The patient was given [100/200] mcg of Phenylephrine every 3-5 minutes to a total of [###] mcg (max 1000 mcg) with [significant improvement in/resolution of] priapism.

The patient tolerated the procedure well without complications.

Procedure Note - Epley Maneuver (Vertigo)

Epley maneuver performed at the bedside at this time.  

Patient initially placed in seated position with legs fully extended and the head rotated 45° to the [right/left same side as positive Dix-Hallpike].  The patient was then quickly lowered into a supine position with the head held approximately in a 30° neck extension with the head still rotated to the [right/left].  The patient was noted to have [no horizontal/vertical] nystagmus with this movement, suggestive of the 'primary stage' of the maneuver.  The patient was left in this position for 1-2 minutes.  The patient's head was then rotated 90° in the opposite direction with the neck still approximately in 30° of extension.  The patient was left in this position for 1-2 minutes.  Keeping the head in this fixed position, the patient rolled onto their shoulder with the head rotated 45° in a downward position, and was noted to have [no horizontal/vertical] nystagmus, suggestive of the 'secondary stage' of the maneuver.  The patient remained in this position for 1-2 minutes.  Finally, the patient was slowly brought to an upright sitting position, while maintaining the 45° rotation of the head, and remained seated for 30 seconds.

The patient reported [no significant/minimal] improvement in vertigo at the end of the procedure.

https://www.mountsinai.on.ca/care/fammed/patient-resources/neurology/epley-maneuver.pdf

Ultrasound - FAST Exam (Normal)

Ultrasound: FAST Exam

A FAST exam was performed by [myself/Dr. Resident under my supervision/independently with images reviewed by myself] in the evaluation of patient with [describe trauma]. 

The peritoneal spaces were assessed in the subphrenic, Morrison’s pouch, splenorenal, superior colic gutters, and retrovesicular spaces for free fluid.  Cardiac views were also obtained to assess for cardiac activity and the presence of fluid in the pericardial sac. 

No intraperitoneal free fluid was noted.  No pericardial effusion was noted.

IMPRESSION:

Normal FAST exam.

https://www.wikem.org/wiki/FAST_exam

Ultrasound - FAST Exam (Positive)

Ultrasound: FAST Exam

A FAST exam was performed by [myself/Dr. Resident under my supervision/independently with images reviewed by myself] in the evaluation of patient with [describe trauma]. 

The peritoneal spaces were assessed in the subphrenic, Morrison’s pouch, splenorenal, superior colic gutters, and retrovesicular spaces for free fluid.  Cardiac views were also obtained to assess for cardiac activity and the presence of fluid in the pericardial sac. 

Free fluid was noted in the [right/left upper quadrant/subxiphoid/bladder] view concerning for intraperitoneal hemorrhage.

IMPRESSION:

Positive FAST exam in the [right/left upper quadrant/subxiphoid/bladder] view.

https://www.wikem.org/wiki/FAST_exam

Ultrasound - Right Upper Quadrant (Normal)

Ultrasound: Right Upper Quadrant

A focused ultrasound exam of the right upper quadrant was performed by [myself/Dr. Resident under my supervision/independently with images reviewed by myself] in the evaluation of patient with [describe complaint].  Long and transverse views of the gallbladder were obtained. 

Sonographic Murphy’s sign was noted to be [absent/present].  The patient was noted to have [no evidence of gallstones/a single gallstone measuring ## mm/several small gallstones/sludge in the gallbladder without clear stone].  The patient was noted to have no evidence of pericholecystic fluid.  The anterior gallbladder wall was noted to measure <3 mm.  The common bile duct [was/was not] visualized [and noted to measure </>7 mm].

IMPRESSION:

Normal gallbladder study with no evidence of cholelithiasis or cholecystitis.

https://www.wikem.org/wiki/Biliary_ultrasound

Ultrasound - Right Upper Quadrant (Abnormal)

Ultrasound: Right Upper Quadrant

A focused ultrasound exam of the right upper quadrant was performed by [myself/Dr. Resident under my supervision/independently with images reviewed by myself] in the evaluation of patient with [describe complaint].  Long and transverse views of the gallbladder were obtained. 

Sonographic Murphy’s sign was noted to be [absent/present].  The patient was noted to have [a single gallstone measuring ## mm/several small gallstones/sludge in the gallbladder without clear stone].  The patient was noted to have [no evidence of/a small amount of] pericholecystic fluid.  The anterior gallbladder wall was noted to measure [<3 mm/>3 mm].  The common bile duct [was/was not] visualized [and noted to measure </>7 mm].

IMPRESSION:

Findings consistent with [cholelithiasis with/without evidence of gallbladder wall thickening/pericholecystic fluid and other findings suggestive of cholecystitis].

https://www.wikem.org/wiki/Biliary_ultrasound

Ultrasound - Abdominal Aortic Aneurysm (Normal)

Ultrasound: Abdominal Aortic Aneurysm

A focused ultrasound of the aorta was performed by [myself/Dr. Resident under my supervision/independently with images reviewed by myself] in the evaluation of patient with [describe complaint].  

The abdominal aorta was examined in both transverse and longitudinal views from the diaphragmatic hiatus to the aortic bifurcation.

Measurements of the proximal, middle, and distal aorta were all noted to be <3 cm.

IMPRESSION:

Normal abdominal aorta exam with no evidence of aneurysm.

https://www.wikem.org/wiki/Aortic_ultrasound

Ultrasound - Pelvis (No Clear IUP)

Ultrasound: Pelvic

A focused [transabdominal/transvaginal] ultrasound of the pelvis was performed by [myself/Dr. Resident under my supervision/independently with images reviewed by myself] in the evaluation of patient with [describe complaint]. 

Long and short views of the uterus were obtained including the pouch of Douglas.  The right and left adnexa [were/were not] visualized [and were normal/notable for a right-/left-sided cyst].  There was [no evidence/a small amount] of free fluid present.  

No clear evidence of a definitive intrauterine pregnancy (IUP) was identified in the uterus.

IMPRESSION:

No clear evidence of IUP identified.  [No/Minimal] free fluid noted.

https://www.wikem.org/wiki/Ultrasound:_Pelvic

Ultrasound - Pelvis (IUP Identified)

Ultrasound: Pelvic

A focused [transabdominal/transvaginal] ultrasound of the pelvis was performed by [myself/Dr. Resident under my supervision/independently with images reviewed by myself] in the evaluation of patient with [describe complaint]. 

Long and short views of the uterus were obtained including the pouch of Douglas.  The right and left adnexa [were/were not] visualized [and were normal/notable for a right-/left-sided cyst].  There was [no evidence/a small amount] of free fluid present.  

A definitive intrauterine pregnancy (IUP) was identified based on evidence of [a gestational sac (GS)/yolk sac (YS)/fetal pole].  Fetal heart rate [was/was not] measured [at ### beats per minute].  Gestational age was estimated at [##] weeks and [##] days [by crown-rump length (CRL)/biparietal diameter (BPD)].

IMPRESSION:

IUP measuring consistent with a gestational age of [##] weeks and [##] days. No evidence of free fluid noted.

https://www.wikem.org/wiki/Ultrasound:_Pelvic

Ultrasound - Soft Tissue (Abscess)

Ultrasound: Soft Tissue

A focused soft tissue ultrasound of the [location] was performed by [myself/Dr. Resident under my supervision/independently with images reviewed by myself] in the evaluation of patient with [describe complaint].  

Long and transverse views of the [location] were obtained.  Fluid collection consistent with an abscess was noted with a size of [## x ## cm].  Cobble-stoning suggestive of cellulitis [was/was not] present.  A foreign body [was/was not] noted.

IMPRESSION:

Findings consistent with an abscess measuring [## x ## cm] to the [location].

https://www.wikem.org/wiki/Ultrasound:_Soft_tissue

Procedure Note - Incision & Drainage (I&D)

Incision & Drainage Note:

The patient was counseled on the risks, benefits, and alternatives to the procedure, and provided consent.  A timeout procedure was performed prior to initiating the procedure.

The area was prepped and draped in the usual sterile manner.  The site was anesthetized with [##] mL of [lidocaine+/-epinephrine].  A linear incision was made with approximately [##] mL of purulent material drained.  The abscess was explored thoroughly and sequestered pockets were opened.  The wound [was/was not] packed [with iodoform gauze].  Bleeding was minimal.

The patient tolerated the procedure well without complications.  Standard post-procedure care was explained and return precautions were given.

Procedure Note - Splint Placement

Splint Placement Note:

Patient with injury to the [note extremity] and with imaging findings notable for [describe].  The patient was counseled on the risks, benefits, and alternatives to the procedure, and provided consent.  

The [describe extremity] was placed in a [describe splint] using [fiberglass/plaster].  Neurovascular function was assessed before and after splint placement, and noted to be normal.  Capillary refill in the distal extremity was assessed before and after splint placement, and noted to be normal.

The patient tolerated the procedure well without complications.  The patient was provided with [sling/crutches] and given instructions on appropriate splint care, return precautions for evidence of neurovascular compromise, and [weight bearing as tolerated/limit use of extremity].

Procedure Note - Laceration Repair

Laceration Repair Note:

The patient was counseled on the risks, benefits, and alternatives to the procedure, and provided consent.  A timeout procedure was performed prior to initiating the procedure. 

The area was prepped and draped in the usual sterile manner.  The site was anesthetized with [##] mL of [lidocaine+/-epinephrine].  The laceration was irrigated with [##] mL of [normal saline/water], and explored without evidence of significant debris, contamination, or tendon or other deep injury.

The wound edges were approximated with [# sutures] [Nylon/Prolene/Gut] [#]-0 sutures.  The wound was dressed with appropriate bandage [and topical antibiotic ointment].  Bleeding was well controlled with suture repair.  The patient tolerated the procedure well without complications.

Procedure Note - Rapid Sequence Intubation (RSI)

Rapid Sequence Intubation (RSI) Note:

Consent was obtained from [name/relationship] prior to the procedure.  Indications, risks, and benefits were explained to [name/relationship].  [Consent was not obtained due to emergent nature of the procedure.]

A timeout procedure was performed and back-up airway adjuncts were situated at the bedside (video laryngoscopy, bougie, supraglottic airways, and a surgical scalpel for cricothyrotomy).  A decision was made to perform rapid sequence intubation (RSI).  

The patient was preoxygenated using a [BVM connected to oxygen/non-rebreather mask].  The patient was pre-treated with [medication].  The patient was induced with [##] mg of [medication].  The patient was subsequently paralyzed with [##] mg of [medication].  The patient was intubated using [direct/video] laryngoscopy and a size [##] cuffed endotracheal tube with stylet.  The patient was intubated on the [first/second/etc.] attempt. 

Appropriate endotracheal tube position was confirmed by direct visualization of vocal cord passage, condensation in the tube, [capnography/colometric CO₂ indicator], and symmetric breath sounds without epigastric sounds.  The tube was secured at [##] cm at the [lips/teeth]. 

A post-intubation chest x-ray was obtained, and tube was [noted to be in the appropriate position/withdrawn ## cm to appropriate position].

EKG Note

EKG Interpretation

An EKG was obtained in the evaluation at [time] and interpreted at [time].

[Regular sinus rhythm/Sinus tachycardia/bradycardia/Atrial fibrillation] at a rate of [##] beats per minute with a [normal/leftward] axis [with/without] ectopy.  

PR interval [normal/prolonged/shortened] at [##] ms. QRS complex [normal/prolonged/shortened] at [##] ms [consistent with a complete/incomplete right bundle branch block (RBBB)/left bundle branch block (LBBB)].  QT interval [normal/prolonged/shortened] at [##] ms.  

ST segment noted to [have no evidence of elevations or depressions suggestive of acute ischemia or infarction/have elevation at the J point consistent with early repolarization].  T waves noted to have [no evidence of peaked appearance/inversions/acute abnormalities].

A prior EKG was [unavailable/compared to this study with no significant changes/specify].

Must contain ≥3 of the following 6: 1) rate/rhythm, 2) axis, 3) intervals, 4) ST segment changes, 5) comparison to prior, and 6) summary of patient’s clinical condition

https://litfl.com/ecg-library/basics/

Procedure Note - Lumbar Puncture (LP)

Lumbar Puncture Note:

The patient was counseled on the risks, benefits, and alternatives to the procedure, and provided consent.  A timeout procedure was performed prior to initiating the procedure.  

The performing physician and support staff donned appropriate sterile garments, including surgical masks, sterile gloves, and caps.  The patient was placed in the [left/right lateral recumbent/seated and flexed] position with help from the supporting staff.  The area was cleansed and draped in usual sterile fashion using [betadine/chlorhexidine] scrub.  Anesthesia was achieved with [##] mL of lidocaine injected subcutaneously.  

A [##] gauge [##] inch spinal needle was placed in the [L2-L3/L3-L4/L4-L5] interspace.  On the [first/second/etc.] attempt, [clear/bloody/straw-colored] cerebral spinal fluid was obtained.  The opening pressure was [##] cm of H2O. 

CSF was collected into 4 tubes.  These were sent for the usual tests with 1 tube to be held for further analysis if needed.  A sterile bandage was placed over the puncture site.

The patient had no immediate complications and tolerated the procedure well.