Procedure notes document essential information about procedures performed—indication, technique, findings, and complications. According to American College of Surgeons guidance, procedure notes should be completed immediately after procedure while details are fresh. Incomplete documentation results in claim denials, medicolegal vulnerability, and poor care coordination.
12 Required Elements Checklist
Procedure Note Requirements
| # | Element | Example |
|---|---|---|
| 1 | Preoperative diagnosis | "Acute appendicitis" |
| 2 | Postoperative diagnosis | "Perforated appendicitis" |
| 3 | Procedure performed | "Laparoscopic appendectomy, converted to open" |
| 4 | Surgeon and assistants | "Attending: Dr. Smith; Resident: Dr. Jones" |
| 5 | Anesthesia type | "General endotracheal anesthesia" |
| 6 | Indication | "RLQ pain, CT showing acute appendicitis" |
| 7 | Findings | "Appendix inflamed and perforated. Abscess cavity." |
| 8 | Technique description | [Step-by-step procedure details] |
| 9 | Estimated blood loss | "EBL: 50cc" |
| 10 | Specimens | "Appendix sent to pathology in formalin" |
| 11 | Complications | "None" or detailed description |
| 12 | Patient condition/plan | "Stable, to PACU, admit for observation" |
Procedure Note Template
**PROCEDURE NOTE** **Date:** [Date] **Preoperative Diagnosis:** [Diagnosis] **Postoperative Diagnosis:** [Diagnosis—may be same or different] **Procedure:** [Specific procedure name] **Surgeon:** [Name, credentials] **Assistant:** [Name, credentials] **Anesthesia:** [Type] by [Anesthesiologist] **Indication:** [Why procedure was necessary] **Informed Consent:** Informed consent obtained. Risks, benefits, and alternatives discussed including [procedure-specific risks]. All questions answered. Patient agreed to proceed. **Time-Out:** Time-out performed. Correct patient, procedure, and site verified. **Findings:** [Normal and abnormal discoveries] **Technique:** [Step-by-step description enabling another practitioner to understand exactly what was done] **Estimated Blood Loss:** [Amount] **Fluids:** [IV fluids given] **Specimens:** [What was sent to pathology, in what container] **Complications:** [None, or detailed description with management] **Patient Condition:** [Stable/unstable, disposition] **Postoperative Plan:** [Orders, follow-up] [Signature]
Technique Documentation Examples
Central Line Placement
**Technique:** After sterile preparation with chlorhexidine and draping, local anesthesia with 10cc 1% lidocaine was administered. Right internal jugular vein accessed using ultrasound guidance with 18-gauge introducer needle. Guidewire advanced without difficulty. Serial dilation performed. Triple-lumen catheter advanced over wire to 15cm depth. All ports aspirated blood and flushed easily. Catheter secured with 2-0 silk suture. Sterile dressing applied. **Confirmation:** Post-procedure CXR ordered to confirm placement.
Complication Documentation
How to Document Complications
| Situation | Documentation Language |
|---|---|
| No complications | "No complications. Patient tolerated procedure well." |
| Minor expected issue | "Small amount of bleeding at port site easily controlled with pressure." |
| Major complication | "During vessel dissection, inferior mesenteric vein injured causing estimated 200cc blood loss. Vessel repaired primarily with 5-0 Prolene with hemostasis achieved." |
| Technical difficulty | "Initial attempt at IJ access unsuccessful due to thrombosis. Proceeded to subclavian approach with successful access on first attempt." |
Trainee Supervision Documentation
- Direct supervision: "Resident performed procedure under direct attending supervision with attending present throughout and immediately available to intervene."
- Critical portions: "Resident performed majority of procedure with attending performing critical dissection of ureter."
- Teaching case: "Attending performed procedure with resident observing and assisting."
Frequently Asked Questions About Procedure Notes
How detailed should technique documentation be?
Detailed enough for another practitioner to understand exactly what was done. Include specific anatomic landmarks, measurements, and materials used. "Fascia identified at 2.5cm depth. Peritoneum entered sharply. No adhesions encountered." Specificity supports billing and medicolegal protection.
What if pre-op and post-op diagnoses differ?
Document both—this is expected when procedures reveal new findings. Pre-op: "Acute appendicitis." Post-op: "Perforated appendicitis with periappendiceal abscess." Different post-op diagnosis shows procedure-driven diagnostic information.
Should I document complications honestly?
Absolutely—honest documentation protects more than concealment. Courts view concealed complications as evidence of cover-up. Document complications completely including how they were managed: "Pneumothorax identified on post-procedure CXR. Chest tube placed with resolution."
When must procedure notes be completed?
Same day per ACS guidelines and most hospital policies. Complete while details are fresh. Delayed documentation is less accurate and may not meet regulatory requirements. Most facilities require completion within 24 hours maximum.
Can AI help with procedure notes?
Yes, AI tools like River's Procedure Note Generator create procedure-specific templates. Select the procedure type, and the AI generates a structured note with typical steps, prompts for findings and complications, and all required elements. Customize based on actual case specifics.
Complete procedure documentation meets regulatory, billing, and medicolegal requirements. Use River's Procedure Note Generator to ensure nothing is missed.