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PROCEDURE NOTES

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Index of Procedure Notes

  • Arterial Line Placement

  • Arthrocentesis

  • Bartholin Cyst Drainage

  • Blank Procedure Note

  • Burn Care (Debridement and Dressing)

  • Burn Care (Escharotomy and Dressing)

  • Cardioversion

  • Cardioversion (Electrical/Chemical)

  • Central Line

  • Cerumen Removal

  • Chest Tube

  • Conscious Sedation

  • Conscious / Moderate Sedation

  • CPR

  • Critical Care

  • Defibrillation

  • Dental Block

  • Digital Block

  • Ear Foreign Body Removal

  • Emergency Cricothyrotomy

  • NG Tube Placement

  • Paracentesis

  • Pelvic Exam

  • Penile Block

  • Pericardiocentesis

  • Perirectal Abscess Drainage

  • Peritonsillar Abscess Drainage

  • Priapism Drainage

  • Rectal Prolapse Reduction

  • Reduction – Fracture/Dislocation

  • Reduction of Paraphimosis

  • Regional Nerve Block

  • Splinting

  • Staple/Suture Removal

  • Straight Catheterization / Bladder Scan

  • Suprapubic Catheter Insertion

  • Testicular Detorsion

  • Thoracentesis

  • Transvenous Pacemaker

  • Ultrasound-Guided Peripheral IV

  • Vaginal Delivery (Spontaneous)

  • Vaginal Prolapse Reduction

  • Wound Care / Debridement

  • ​Epistaxis

  • Escharotomy

  • Eye Irrigation

  • Fecal Disimpaction

  • Foley Catheter

  • Foreign Body Removal

  • Foreign Body Removal (ENT, Eye, etc.)

  • Fracture Care (Splinting / Reduction)

  • General Procedural Note

  • Incision and Drainage

  • Intraosseous Line Placement

  • Intubation

  • Intranasal Sedation

  • Laceration

  • Lateral Canthotomy

  • Local / Regional Anesthesia

  • Lumbar Puncture

  • Manual Placenta Removal

  • Nail Treatment

  • Nail Trephination (Subungual Hematoma)

  • Nasal Foreign Body Removal

  • Needle Decompression

  • Nerve Block

MDM

  • AMA (Against Medical Advice) Note

  • Critical Care Time Note

  • DNR Discussion and Documentation

  • Postmortem Care and Documentation

  • Restraint Application

  • Sepsis Note

  • Stroke Protocol Note

  • Withholding / Withdrawal of Care

Procedure Notes

Blank Procedure Note Time: [ ] Performed by: [Myself / Resident / PA] Indication: [Fluctuance / Pointing / Hematoma / Abscess / Foreign body / Joint effusion / Other] Location: [ ] Universal Protocol: Time-out performed; patient, side, site, and procedure verified. Consent: [Verbal / Written / Emergent – patient unable to consent]. Indications, risks, and benefits explained. Anesthesia: [ ] mL [1% lidocaine / 2% lidocaine / 0.25% bupivacaine / 0.5% bupivacaine / +Bicarb / With epi / Without epi / None] Preparation: The site was prepped and draped in a sterile fashion. Procedure: [ ] - [Incision / Aspiration / Evacuation / Exploration] performed - [Irrigation: None / Minimal / Moderate / Extensive] - [Debridement: None / Minimal / Moderate / Extensive] - Closure: [None / # Sutures / Staples / Dermabond / Steristrip] – [Simple / Running / Interrupted / Complex] Findings: [Purulent drainage / Hematoma evacuated / Foreign body removed / Serous fluid / Minimal output] Post-procedure exam: Circulation, motor, sensory [Intact / Deficit] Complications: [None / Describe] Tolerance: [Well / Poorly] Disposition: [Stable / Admit / Discharge / OR transfer] Total time: [ ] minutes

CPR Note Time: [ ] Indication: [Cardiopulmonary arrest / Pulseless and apneic] Consent: Unable to obtain due to critical condition Procedure: - Patient noted to be pulseless on exam - Cardiac compressions performed by staff under my direct supervision - Patient ventilated and oxygenated - ACLS measures administered and repeated as necessary - CPR performed per AHA guidelines in addition to other critical activities Total time: Refer to nursing code documentation for start/stop times Findings: [Regained spontaneous circulation with palpable pulse / Expired]

Laceration Repair Note Time: [ ] Confirmed: Patient / Procedure / Side / Site Consent: [Verbal / Written / None] Repair description: - Length: [ ] cm - Location: [ ] - Shape: [Linear / Irregular / Flap / Stellate / Complex / Puncture] - Depth: [Superficial / Subcutaneous / Muscle / Multilayer / Tendon / Fascia] - Details: [Clean / Contaminated / Foreign body / Contused / Abrasion / Swelling / Erythema / Bleeding / Amputation] - Neurovascular/Tendon exam: [Intact / Circulation deficit / Motor deficit / Sensory deficit / Tendon deficit] Anesthesia: [ ] mL [1% lidocaine, with epi / 2% lidocaine / +Bicarb / Local / Digital / Regional / LET / TAC / None] Irrigation: [None / Minimal / Moderate / Extensive] Debridement: [None / Minimal / Moderate / Extensive] Closure: [# Sutures / Staples / Dermabond / Steristrip – Simple / Running / Interrupted / Complex] Layers: [Single / 2-layer / 3-layer / Contaminated] Post-procedure exam: Circulation, motor, sensory [Intact / Deficit] Complications: [None / Describe] Tolerance: [Well / Poorly] Performed by: [Myself / Resident / PA] Total time: [ ] minutes

Cardioversion Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Time-out Consent: [Verbal / Written / Emergent – unable to consent] Indication: [Atrial fibrillation / Atrial flutter / PSVT / Ventricular tachycardia / Hemodynamically unstable] Procedural sedation: [None / IV / IM / Medication] Monitoring: Continuous cardiac, blood pressure, pulse oximetry Cardioversion: - Attempts: [ ] - Medications given: [ ] - Mode: [Synchronized / Unsynchronized] - Energy: [ ] Joules Post-procedure exam: [Sinus rhythm / Rate [ ] / BP [ ]] Complications: [None / Describe] Tolerance: [Well / Poorly] Notes: Patient supine with respiratory therapist and ER nurse at bedside. Total time: [ ] minutes

Central Line Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Signed / Verbal / Emergent – unable to consent] Indication: [Venous access / Hemodynamically unstable / Hemodynamic monitoring / Pacemaker] Monitoring: Continuous cardiac, blood pressure, pulse oximetry Location: [Right / Left] [Internal jugular / Subclavian / Femoral] Preparation: Sterile field, chlorhexidine prep, maximum barrier sterile technique Local anesthesia: [ ] mL [1% lidocaine / 2% lidocaine / With epi / Without epi] Ultrasound guidance: [Yes – image recorded / Yes – image not recorded / No] Procedure: - Device: [Triple lumen / Cordis / Dialysis / Introducer] [ ] French - Technique: [Seldinger / Modified Seldinger] - Attempts: [ ] - Secured at: [ ] cm - Line secured with sutures, biopatch, and Tegaderm applied Post-procedure exam: - Adequate blood return - Good fluid flow - Equal bilateral breath sounds - Circulation, motor, sensory [Intact / Deficit] Complications: [None / Describe] Tolerance: [Well / Poorly] Total time: [ ] minutes

Chest Tube Note Date/Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Responsible party / Legal guardian / Emergent – unable to consent] Indication: [Pneumothorax / Hemothorax / Pleural effusion / Empyema / Other] Procedural sedation: [None / IV [ ] / IM [ ] / Medication: [ ] / See nurse's notes] Monitoring: Continuous cardiac, blood pressure, pulse oximetry Technique: - Location: [Right / Left / Bilateral] – [Midaxillary line / Midclavicular line / Other] - Anesthesia: [ ] mL [1% lidocaine / 2% lidocaine / 0.25% bupivacaine / With epi / Without epi / +Bicarb / Local] - Preparation: [Sterile field / Chlorhexidine / Betadine / Other] - Chest tube size: [ ] French - Tube directed: [Superiorly (air) / Inferiorly (fluid)] - Return: [None / Air / Bloody / Serous / Purulent] – [ ] mL - Secured with: [Suture / Lubricated gauze / Adhesive tape / Other] Post-procedure exam: Bilateral breath sounds [Equal / Unequal] Chest X-ray: [Good tube placement / Expanded lung fields bilaterally / Other] Complications: [None / Describe] Tolerance: [Well / Poorly] Total time: [ ] minutes

Conscious Sedation Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Time-out Consent: [Verbal / Written / Parent / Legal guardian / Emergent – unable to consent] Indication: [Closed reduction / Fracture manipulation / Laceration repair / Incision & drainage / Cardioversion / Other] Monitoring: Continuous cardiac, blood pressure, pulse oximetry Preparation: Suction available, IV access, constant attendance, supplemental oxygen ASA Class: [I Healthy / II Mild systemic disease / III Severe systemic disease – not life threatening / IV Severe systemic disease – life threatening / V Moribund – not expected to live 24 hours] Mallampati score: [I Full soft palate / II Uvula partially visible / III Base of uvula only / IV Soft palate not visible] Physical exam: [See physical exam] Pre-sedation vital signs: [See nursing documentation] Procedural sedation: - Medication: [Propofol / Ketamine / Etomidate / Midazolam / Fentanyl / Other] - Dose: [ ] [mg / mcg] - Route: [IV / IM / PO / IN] Post-procedure exam: [See nursing documentation / Stable / Unstable] Complications: [None / Describe] Tolerance: [Well / Poorly] Total intraservice time: [ ] minutes Notes: Sedation protocol followed. Nurse and respiratory therapist present and monitored vital signs and cardiorespiratory status throughout.

Digital Nerve Block Note Time: [ ] Performed by: [Myself / Resident / PA] Procedure: Digital nerve block Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Responsible party / Emergent – unable to consent] Location: [Digit / Right / Left / Hand / Foot] Preparation: [Chlorhexidine / Betadine / Alcohol] Anesthesia: - Medication: [1% lidocaine / 2% lidocaine / +Epi / Without epi / Bupivacaine / Other] - Volume: [ ] mL Patient tolerated: [Well / Poorly] Complications: [None / Describe] Total time: [ ] minutes

Epistaxis Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Side / Site Consent: [Verbal / Written / Legal guardian / Emergent – unable to consent] Location: [Right / Left / Bilateral] – [Anterior / Posterior] Preparation: [External pressure / Nasal evacuation of blood & clots / Topical vasoconstrictor] Procedure: - Attempt #: [ ] - Intervention: [Packing with nasal rocket / Rapid Rhino / Silver nitrate cautery / Topical agent / Other] Post-procedure bleeding: [None / Minimal / Persistent] Patient tolerated: [Well / Poorly] Complications: [None / Describe] Follow-up: [Primary care provider / ENT / Return to ED if recurrent] Total time: [ ] minutes

Foreign Body Removal Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Responsible party / Legal guardian / Emergent – unable to consent] Procedural sedation: [None / IV [ ] / IM [ ] / PO [ ] / Medication: [ ] Monitoring: Cardiac, BP, pulse oximetry Description: - Location: [Face / UE / Hand / Finger / LE / Foot / Toe / Other] - Foreign body type: [Debris / Glass / Wood / Metal / Not identified] - Depth: [Superficial / Subcutaneous / Muscle / Multi-layer / Tendon / Fascia] - Associated findings: [Contused tissue / Abrasion / Swelling / Erythema / Bleeding] - Neurovascular/Tendon exam: [Intact / Deficit] Anesthesia: [ ] mL [1% lidocaine / 2% lidocaine / +Epi / Without epi / Local / Digital / Regional / Other] Preparation: [Sterile field / Betadine / Chlorhexidine / Soap] Irrigation: [Copious saline / Other] Technique: [Exploration / Forceps removal / Needle extraction / Other] Post-procedure exam: Bleeding controlled, foreign body [Completely removed / Not visualized / Residual fragment suspected] Patient tolerated: [Well / Poorly] Complications: [None / Describe] Total time: [ ] minutes

Reduction, Fracture/Dislocation Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Legal guardian / Emergent – unable to consent] Indication: [Dislocation / Fracture / Fracture-dislocation] Location: [Right / Left / Bilateral] [Shoulder / Elbow / Wrist / Hip / Knee / Ankle / Finger / Toe / Other] Pre-procedure exam: Circulation, motor, sensory [Intact / Deficit] Procedural sedation: [See nurse documentation / None / IV [ ] / IM [ ] / Medication: [ ]] Monitoring: Continuous cardiac, BP, pulse oximetry Technique: [Traction-countertraction / Flexion-extension / External rotation / Direct pressure / Other] Reduction result: [Successful / Unsuccessful / Partial alignment] Post-reduction exam: Circulation, motor, sensory [Intact / Deficit] Immobilization: [Splint / Sugar-tong / Coaptation / Gutter / Thumb spica / Sling / Cast / Other] Post-immobilization exam: Distal neurovascular [Normal / Deficit] Patient tolerated: [Well / Poorly] Complications: [None / Describe] Total time: [ ] minutes

Intubation Note Time: [Insert time] Confirmed Correct: Patient, procedure, side, site Consent: Verbal consent unable to be obtained due to clinical status / Consent obtained Indication: Respiratory failure / Airway protection / Altered mental status / Other Pre-oxygenation: Bag-valve-mask / Non-rebreather / Nasal cannula Medications: RSI performed with [Insert medication] for sedation and [Insert medication] for paralysis Blade: Mac / Miller, size [Insert size] Tube Size: [Insert tube size] Number of Attempts: [Insert # of attempts] Vocal cords visualized: Yes / No Tube placement confirmed by: Direct visualization / End-tidal CO2 / Auscultation / Chest rise / CXR Post-intubation sedation: [Insert medication] Complications: None / Hypoxia / Esophageal intubation / Bradycardia / [Other] Patient Tolerated Procedure: Well Performed By: Myself / [Other provider] Total Time: [Insert minutes]

Incision and Drainage Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to consent] Indication: [Abscess / Wound infection / Effusion / Wound seroma / Hematoma / Other] Pre-procedure exam: Circulation, motor, sensory [Intact / Deficit] Location: [Right / Left / Bilateral] [Scalp / Face / Upper extremity / Hand / Finger / Trunk / Lower extremity / Foot / Toe / Other] Anesthesia: [ ] mL [1% lidocaine / 2% lidocaine / +Epi / Without epi / Other] Preparation: [Sterile field / Soap / Betadine / Chlorhexidine / Other] Incision: [ ] cm using #11 scalpel Technique: [Gauge needle decompression / Manual decompression / Wound probed / Loculations decompressed] Drainage: [Small / Moderate / Large / Clear / Purulent / Bloody / Serosanguineous / Cultures obtained] – Volume [ ] mL Irrigation: Copious saline [ ] mL Wound care: [Packing placed / Drain placed / Left open] Post-procedure exam: Circulation, motor, sensory [Intact / Deficit] Patient tolerated: [Well / Poorly] Complications: [None / Describe] Total time: [ ] minutes

Lumbar Puncture Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Signed / Emergent – unable to consent] Indication: [Headache / Possible meningitis / Possible SAH / Neurologic workup / Other] Pre-procedure exam: Circulation, motor, sensory [Intact / Deficit] Procedural sedation: [None / IV [ ] / IM [ ] / Other] Monitoring: Continuous cardiac, blood pressure, pulse oximetry Patient position: [Sitting, leaning forward / Lateral decubitus, right side / Lateral decubitus, left side] Location: [L3–L4 / L4–L5 / L5–S1] Preparation: Sterile field, [Betadine / Chlorhexidine / Other]; local anesthesia [ ] mL 1% lidocaine [With epi / Without epi] Technique: [20 / 22 / Other] gauge spinal needle; specimen obtained and sent to lab Fluid return: [Clear / Xanthochromic / Pink / Bloody / Traumatic tap] – Volume: [ ] mL collected Post-procedure exam: Circulation, motor, sensory [Intact / Deficit]; bleeding controlled Patient tolerated: [Well / Poorly] Complications: [None / Describe] Total time: [ ] minutes

Nail Treatment Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to consent] Indication: [Subungual hematoma / Nail avulsion / Nail bed injury / Paronychia / Other] Location: [Right / Left / Bilateral] [Finger / Toe / Other] Preparation: [Digital block / Local infiltration / None] Procedure: - Trephination: [Yes / No] – technique: [Electrocautery / 18g needle / Other] - Nail removal: [Partial / Complete] avulsion using [Scissors / Elevator / Forceps] - Nail bed: [Intact / Repaired with suture / Dermabond / Left open] - Wound care: [Irrigated / Packed / Antibiotic ointment applied / Dressing placed] Post-procedure exam: Circulation, motor, sensory [Intact / Deficit] Patient tolerated: [Well / Poorly] Complications: [None / Describe] Total time: [ ] minutes

Pericardiocentesis Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Time-out / Patient / Procedure / Site Consent: [Verbal / Written / Legal guardian / Emergent – unable to consent] Indication: [Cardiac tamponade / Pericardial effusion / Diagnostic aspiration / Therapeutic drainage] Procedural sedation: [None / IV [ ] / IM [ ] / Medication: [ ]] Monitoring: Continuous cardiac, blood pressure, pulse oximetry Preparation: Sterile field, [Chlorhexidine / Betadine / Other] Local anesthesia: [ ] mL [1% lidocaine / 0.5% bupivacaine / Other] Technique: [Subxiphoid / Parasternal / Apical] approach with [ ] gauge needle Aspirate: [None / Clear / Pink / Bloody / Cloudy / Purulent / Air] – Volume [ ] mL Post-procedure exam: [Equal breath sounds / Normal S1-S2 / Other] Post-procedure rhythm: [NSR / Ectopy / PVCs / PACs / V-tach / V-fib / Other] Patient condition: [Improved / Unchanged / Worsened] Patient tolerated: [Well / Poorly] Complications: [None / Describe] Total time: [ ] minutes

Paracentesis Note Time: [ ] Performed by: [Myself / Resident / PA] Consent: [Verbal / Written / Guardian / Emergent – unable to consent] Risks, benefits, and alternatives discussed with patient. Patient verbalized understanding and agreed. Confirmed: Patient identity (armband + verbal), Procedure, Site, Time-out performed Required items (equipment, blood products, devices) available Indication: [Ascites / Diagnostic / Therapeutic / Other] Ultrasound: [Used to confirm needle placement / Not used] Preparation: Patient prepped and draped in sterile fashion Anesthesia: Local infiltration with [ ] mL [1% lidocaine without epi / 1% lidocaine with epi / Other] Sedation: [None / IV [ ] / IM [ ] / Other] Technique: Needle/catheter advanced into peritoneal cavity; [ ] liters removed Fluid appearance: [Clear / Straw-colored / Bloody / Chylous / Purulent / Other] Specimen: [Sent for analysis / Not sent] Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Bowel injury / Hypotension / Other] Post-procedure condition: [Stable / Improved / Worsened] Total time: [ ] minutes

Priapism Drainage Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Emergent – unable to consent] Indication: Persistent, painful erection Location: Bilateral corpora cavernosa Procedural medications: [Morphine / Dilaudid / Ativan / Zofran / None / Other] Anesthesia: Local infiltration with lidocaine 1% without epinephrine at 10 and 2 o’clock positions; patient tolerated well and was sufficiently anesthetized Technique: - Intracavernous injection: [ ] mL phenylephrine - Aspiration: [ ] mL blood aspirated using [18G angiocath / Other] - Result: [Detumescence achieved / Partial response / No response] Post-procedure exam: Penis flaccid; 4x4 gauze and Coban wrap applied to decrease localized edema Patient tolerated: [Well / Poorly] Complications: [None / Describe] Total time: [ ] minutes Notes: Patient able to urinate post-procedure; pain improved

Regional Nerve Block Note Time: [ ] Performed by: [Myself / Resident / PA] Procedure: Regional nerve block Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to consent] Indication: [Analgesia / Pre-procedure anesthesia / Other] Location: [Right / Left / Bilateral] [Supraorbital / Infraorbital / Submental / Auricular / Digital / Median / Radial / Ulnar / Femoral / Other] Patient position: [Supine / Sitting / Other] Preparation: [Chlorhexidine / Betadine / Alcohol]; sterile draping applied Monitoring: Cardiac, BP, pulse oximetry Local infiltration for anesthesia: [ ] mL [1% lidocaine / 2% lidocaine / Other] Needle: [22G / 18G spinal / Other] Technique: - Guidance: [Anatomic landmarks / Ultrasound-guided] - If ultrasound: High-frequency linear probe used; relevant anatomy and vasculature identified; sterile probe cover and gel applied - Needle advanced under [In-plane / Out-of-plane] ultrasound visualization - Aspiration negative for blood before injection Injectate: - Mixture: [ ] mL [1% lidocaine / 2% lidocaine / 0.5% bupivacaine / Other] - Administered in aliquots with aspiration every 5 mL to avoid intravascular injection - Injection without resistance; no intravascular uptake observed Post-procedure exam: Block assessed after [ ] minutes and appeared [Effective / Ineffective / Partial] Patient tolerated: [Well / Poorly] Complications: [None / Paresthesia / Vascular puncture / Local anesthetic toxicity / Other] Total time: [ ] minutes

Splinting Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to consent] Indication: [Fracture / Dislocation / Sprain / Immobilization / Other] Location: [Right / Left / Bilateral] [Upper extremity / Lower extremity / Hand / Finger / Wrist / Forearm / Elbow / Shoulder / Ankle / Foot / Knee / Other] Pre-procedure exam: Circulation, motor, sensory [Intact / Deficit] Immobilization applied: [Splint / Sugar-tong / Coaptation / Gutter / Thumb spica / Knee immobilizer / Ace wrap / Sling / Other] Post-procedure exam: Circulation, motor, sensory [Intact / Deficit] Post-splint distal neurovascular exam: [Normal / Deficit] Patient tolerated: [Well / Poorly] Complications: [None / Skin breakdown / Pressure points / Other] Total time: [ ] minutes

Staple/Suture Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Responsible party / Emergent – unable to consent] Location: [Right / Left / Bilateral] [Face / Upper extremity / Hand / Finger / Lower extremity / Foot / Toe / Other] Neurovascular/Tendon exam: [Intact / Deficit] Anesthesia: [None / Local infiltration / Other] Procedural sedation: None Monitoring: None Description: [ ] [Staples / Sutures] removed; bleeding controlled Post-procedure exam: Wound [Well-healed / Not well-healed / Dehisced / Other] Dressing: [None / Steri-strips / Antibiotic ointment / Bandage / Other] Patient tolerated: [Well / Poorly] Complications: [None / Infection / Bleeding / Dehiscence / Other] Total time: [ ] minutes

Transvenous Pacemaker Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to consent] Indication: [Bradycardia / Asystole / Unstable heart block / Other] Procedural sedation: [None / IV [ ] mg / IM [ ] mg / Other] Monitoring: Continuous cardiac, blood pressure, pulse oximetry Preparation: Sterile field; skin prepped with [Chlorhexidine / Betadine / Other]; local anesthesia [None / 1% lidocaine / 2% lidocaine / With epi / Without epi] Technique: Seldinger technique via [Right / Left] [Subclavian / Internal jugular / Femoral] vein; [ ] French catheter advanced into right ventricle under guidance Ventricular pacing achieved at: - Capture threshold: [ ] mA - Rate: [ ] BPM - Final settings: [ ] Post-procedure exam: Equal breath sounds bilaterally; CXR confirmed line in good position Patient tolerated: [Well / Poorly] Complications: [None / Pneumothorax / Bleeding / Arrhythmia / Other] Total time: [ ] minutes

Needle Decompression Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Unable to obtain – emergent] Indication: [Tension pneumothorax / Traumatic pneumothorax / Other] Site: [Right / Left] 2nd intercostal space, midclavicular line Preparation: Sterile technique with gloves and [Chlorhexidine / Betadine / Other] Needle size: [14G / 16G / Other] Procedure: Needle inserted; immediate release of air [Confirmed / Not confirmed] Number of attempts: [ ] Post-procedure: - Patient reassessed; [Chest rise improved / No improvement] - CXR [Ordered / Not ordered] Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Infection / Misplacement / Other] Total time: [ ] minutes

Emergency Cricothyrotomy Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Site / Time-out Consent: [Unable to obtain – emergent / Verbal / Other] Indication: [Failed airway / Inability to intubate / Severe airway obstruction / Other] Site: Cricothyroid membrane Preparation: Sterile technique with [Chlorhexidine / Betadine / Other]; sterile gloves and drape applied Anesthesia: [None / Local 1% lidocaine [ ] mL] Procedure: - Vertical incision over cricothyroid membrane - Membrane palpated; horizontal incision made - [Endotracheal tube / Tracheostomy tube] size [ ] inserted and secured - Number of attempts: [ ] Confirmation of placement: - [Bilateral chest rise / Capnography waveform / Color change / Auscultation of equal breath sounds / Other] Post-procedure: Tube secured; patient ventilated Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Infection / Subcutaneous emphysema / Misplacement / Other] Total time: [ ] minutes

Arterial Line Placement Note Time: [ ] Performed by: [Myself / Resident / PA] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Unable to obtain – emergent] Indication: [Hemodynamic monitoring / Frequent blood gas analysis / Other] Site: [Right / Left] [Radial artery / Femoral artery / Brachial artery / Other] Preparation: Sterile technique with [Chlorhexidine / Betadine / Other], sterile gloves, and drape applied Anesthesia: [None / Local 1% lidocaine [ ] mL] Procedure: - Needle inserted into artery - Guidewire advanced, catheter placed using Seldinger technique - Arterial waveform confirmed on monitor - Number of attempts: [ ] Post-procedure: - Catheter secured and sterile dressing applied - Arterial waveform confirmed on monitor Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Infection / Thrombosis / Hematoma / Other] Total time: [ ] minutes

Thoracentesis Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: [Pleural effusion / Diagnostic evaluation / Therapeutic removal of fluid / Other] Site: [Right / Left] [ ] intercostal space Preparation: Sterile technique with [Chlorhexidine / Betadine / Other]; sterile gown, gloves, and drape applied Anesthesia: [ ] mL [1% lidocaine / Other] Needle size: [18G / 20G / Other] Amount of fluid removed: [ ] mL Fluid appearance: [Clear / Serosanguinous / Bloody / Purulent / Chylous / Other] Samples sent for: [Cell count / Protein / LDH / Culture / Cytology / Other] Post-procedure: - Chest X-ray [Performed / Not performed] to assess for pneumothorax - Site covered with sterile dressing Patient tolerated: [Well / Poorly] Complications: [None / Pneumothorax / Bleeding / Infection / Other] Total time: [ ] minutes

Arthrocentesis (Joint Aspiration) Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: [Joint effusion / Suspected septic arthritis / Gout / Diagnostic / Therapeutic / Other] Site: [Right / Left] [Shoulder / Elbow / Wrist / Knee / Ankle / Other] Preparation: Sterile technique with [Chlorhexidine / Betadine / Other]; sterile gown, gloves, and drape applied Anesthesia: [ ] mL [1% lidocaine / Other] Needle size: [18G / 20G / Other] Amount of fluid removed: [ ] mL Fluid appearance: [Clear / Cloudy / Bloody / Purulent / Other] Samples sent for: [Cell count / Crystals / Gram stain / Culture / Other] Post-procedure: Sterile dressing applied; patient monitored for complications Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Infection / Other] Total time: [ ] minutes

Cardioversion Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Unable to obtain – emergent] Indication: [Atrial fibrillation / Atrial flutter / SVT / Ventricular tachycardia / Other] Type: [Electrical / Chemical] --- ELECTRICAL CARDIOVERSION --- Energy delivered: [ ] Joules Pad position: [Anterior-posterior / Anterior-lateral] Sedation: [Propofol / Etomidate / Midazolam / Fentanyl / None / Other] Number of shocks: [ ] Rhythm post-cardioversion: [Normal sinus rhythm / Atrial fibrillation / Atrial flutter / Other] --- CHEMICAL CARDIOVERSION --- Medication: [Adenosine / Amiodarone / Diltiazem / Other] Dose: [ ] mg IV Rhythm post-cardioversion: [Normal sinus rhythm / Atrial fibrillation / Atrial flutter / Other] Complications: [None / Hypotension / Bradycardia / Arrhythmia / Other] Post-procedure: Continuous cardiac monitoring; patient monitored for stability Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Conscious/Moderate Sedation Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: [Fracture reduction / Cardioversion / Abscess drainage / Other] Sedation medications: [Midazolam / Fentanyl / Ketamine / Propofol / Other] Dose/route: [ ] mg via [IV / IM / Other] Monitoring: Continuous cardiac, pulse oximetry, and BP per nursing documentation Oxygen delivery: [Nasal cannula / Non-rebreather / Bag-valve-mask / Other] Start/end times: See nursing documentation Total intraservice sedation time: [ ] minutes (per nursing record) Sedation level: [Minimal / Moderate / Deep] Complications: [None / Hypoxia / Hypotension / Bradycardia / Other] Post-procedure: Patient recovered to baseline, vitals stable, monitored in recovery Discharge instructions: [Given to patient / Given to caregiver / Not applicable] Patient tolerated: [Well / Poorly]

Foreign Body Removal Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: Foreign body in [Eye / Ear / Nose / Skin / Other] Location: [Right / Left / Bilateral] [Specific site] Foreign body type: [Metal / Wood / Glass / Organic material / Plastic / Other] Anesthesia: [None / Local 1% lidocaine [ ] mL / Other] Preparation: Sterile technique with [Chlorhexidine / Betadine / Alcohol / Other]; sterile gloves and drape applied Method of removal: [Forceps / Irrigation / Suction / Magnet / Needle / Other] Number of attempts: [ ] Result: [Foreign body removed completely / Partial removal / Unable to visualize] Post-procedure exam: [Circulation, motor, sensory intact / No deficit / Other] Dressing: [None / Steri-strips / Bandage / Antibiotic ointment / Other] Complications: [None / Bleeding / Infection / Residual foreign body suspected / Other] Follow-up: [Primary care / ENT / Ophthalmology / Return to ED if worsening / Other] Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Wound Care/Debribement Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: [Wound requiring debridement / Necrotic tissue / Infected wound / Other] Location: [Right / Left / Bilateral] [ ] Wound size: [ ] cm Anesthesia: [None / Local 1% lidocaine [ ] mL / Other] Preparation: Sterile technique with [Chlorhexidine / Betadine / Other]; sterile gloves, gown, and drape applied Type of debridement: [Sharp / Mechanical / Enzymatic / Autolytic] Extent of debridement: [Minimal / Moderate / Extensive] Tissue removed: [Necrotic / Infected / Foreign material / Other] Post-procedure: Wound cleaned and dressed with [Gauze / Steri-strips / Wet-to-dry / Other]; patient advised on wound care and signs of infection Follow-up: [Primary care / Wound care clinic / Surgical consult / Return to ED if worsening / Other] Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Infection / Other] Total time: [ ] minutes

Nail Trephination (Subungal Hematoma) Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: Subungual hematoma Location: [Right / Left] [Finger / Toe / Other] Size of hematoma: [ ] % of nail Anesthesia: [None / Local 1% lidocaine [ ] mL / Other] Preparation: Sterile technique with [Alcohol / Chlorhexidine / Betadine / Other]; sterile gloves applied Method: [Electrocautery / Needle / Paperclip / Other] Relief of pressure: [Successful / Unsuccessful] Amount of blood drained: [Small / Moderate / Large / [ ] mL] Post-procedure: Sterile dressing applied; patient advised on infection signs and potential nail loss Follow-up: [Primary care / Hand specialist / Return to ED if worsening / Other] Patient tolerated: [Well / Poorly] Complications: [None / Infection / Nail bed injury / Other] Total time: [ ] minutes

Foley Catheter Insertion Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: [Urinary retention / Monitoring urine output / Other] Preparation: Sterile technique with [Chlorhexidine / Betadine / Other]; sterile gloves and drape applied Catheter size: [ ] French Foley Number of attempts: [ ] Balloon inflated with [ ] mL sterile water Urine output: [None / [ ] mL obtained / Clear / Cloudy / Bloody / Other] Post-procedure: Catheter secured; drainage bag attached Patient tolerated: [Well / Poorly] Complications: [None / Urethral trauma / Infection / Other] Total time: [ ] minutes

Ultrasound-Guided Peripheral IV Placement Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: [Difficult IV access / Need for IV fluids / Medications / Other] Site: [Right / Left] [Forearm / Upper arm / Antecubital / Hand / Other] Preparation: Sterile technique with [Chlorhexidine / Betadine / Other]; sterile gloves applied Ultrasound guidance: [Yes / No] – vein visualized with [Linear probe / Other] Catheter size: [18G / 20G / 22G / Other] Number of attempts: [ ] Successful cannulation: [Yes / No] Post-procedure: IV flushed and patent; secured with sterile dressing Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Infection / Hematoma / Other] Total time: [ ] minutes

Pelvic Exam Procedure Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: [Abdominal pain / Vaginal bleeding / Suspected infection / Other] Position: Lithotomy External genitalia: [Normal / Lesions / Erythema / Swelling / Other] Vaginal vault: [Normal / Discharge / Blood / Lesions / Other] Cervix: [Closed / Open / Erythematous / Discharge / Lesions / Other] Bimanual exam: [Uterus normal size / Adnexal tenderness / Cervical motion tenderness / Other] Samples obtained: [Wet mount / GC/Chlamydia swab / Pap smear / Other] Complications: [None / Patient discomfort / Bleeding / Other] Post-procedure: Patient advised regarding lab follow-up and further care Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Fecal Disimpaction Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: [Constipation / Fecal impaction / Incomplete bowel evacuation / Other] Patient position: [Lateral / Lithotomy / Supine / Other] Preparation: Sterile technique with gloves and lubricant applied Method: [Manual disimpaction / Instrument-assisted / Other] Amount of stool removed: [Small / Moderate / Large / Other] Stool consistency: [Hard / Soft / Mixed / Other] Post-procedure: Patient advised regarding bowel care regimen and follow-up if symptoms persist Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Rectal pain / Other] Total time: [ ] minutes

Testicular Detorsion Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: Suspected testicular torsion Side: [Right / Left] Pre-procedure exam: [High-riding testicle / Absent cremasteric reflex / Swelling / Tenderness / Other] Preparation: Sterile technique with gloves applied Method: [Manual outward (lateral) rotation / Other] Number of attempts: [ ] Post-procedure exam: [Testicle lower / Improved blood flow / Pain relief / Persistent symptoms / Other] Confirmation of detorsion: [Doppler ultrasound / Clinical improvement / Both / Other] Complications: [None / Persistent torsion / Other] Post-procedure: Patient advised to follow-up with urology for definitive management (surgical fixation) Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Vaginal Delivery (Spontaneous) Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: [Full-term pregnancy / Preterm labor / Other] Gestational age: [ ] weeks Position of patient: Lithotomy Preparation: Sterile technique with drapes, gown, gloves, and mask applied Stage of labor: [Active / Transition / Other] Fetal position: [Cephalic / Breech / Other] Delivery: [Normal spontaneous vaginal delivery – head delivered first, followed by shoulders and body] Episiotomy: [None / Mediolateral / Midline] Perineal tear: [None / First-degree / Second-degree / Third-degree / Fourth-degree] Cord clamping: [Delayed / Immediate] Placenta delivery: [Spontaneous / Assisted / Manual removal] Placenta appearance: [Intact / Retained fragments / Other] Post-delivery uterine tone: [Firm / Boggy] Postpartum bleeding: [Normal / Excessive] Complications: [None / Shoulder dystocia / Postpartum hemorrhage / Fetal distress / Other] Post-procedure: Fundal massage performed; patient monitored for postpartum hemorrhage; newborn handed to pediatric team for care Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Perirectal Abscess Drainage Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: Perirectal abscess Location: [Right / Left / Bilateral / Other] [ ] Size: [ ] cm Anesthesia: [Local 1% lidocaine [ ] mL / Other / None] Preparation: Sterile technique with [Chlorhexidine / Betadine / Other]; sterile gown, gloves, and drape applied Procedure: - Incision made with [Scalpel #11 / Other] - Amount of pus drained: [Small / Moderate / Large / [ ] mL] - Culture obtained: [Yes / No] - Irrigation performed with [Normal saline / Other] - Packing: [Yes / No] – if yes, material: [Iodoform gauze / Other] Post-procedure exam: Circulation, motor, sensory [Intact / Deficit] Complications: [None / Bleeding / Infection / Other] Post-procedure care: Sterile dressing applied; patient advised on wound care and follow-up if symptoms worsen Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Bartholin Cyst Drainage Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: [Bartholin gland cyst / Bartholin abscess] Side: [Right / Left] Size: [ ] cm Anesthesia: [Local 1% lidocaine [ ] mL / Other / None] Preparation: Sterile technique with [Chlorhexidine / Betadine / Other]; sterile gown, gloves, and drape applied Procedure: - Incision made with [Scalpel #11 / Other] - Amount of pus/fluid drained: [Small / Moderate / Large / [ ] mL] - Culture obtained: [Yes / No] - Word catheter placed: [Yes / No] - Packing: [Yes / No] – if yes, material: [Iodoform gauze / Other] Post-procedure exam: Circulation, motor, sensory [Intact / Deficit] Complications: [None / Bleeding / Infection / Other] Post-procedure care: Sterile dressing applied; patient advised on wound care and catheter care instructions Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Escharotomy Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Unable to obtain – emergent] Indication: [Full-thickness circumferential burn / Compartment syndrome / Impaired circulation / Other] Location: [Right / Left / Bilateral] [Upper extremity / Lower extremity / Chest / Abdomen / Other] Preparation: Sterile technique with [Chlorhexidine / Betadine / Other]; sterile gown, gloves, and drape applied Anesthesia: [None / Local 1% lidocaine [ ] mL / Sedation / Other] Procedure: - Incision made along the length of the burn eschar - Depth: Through eschar into subcutaneous tissue - Number of incisions: [ ] - Improved circulation confirmed by: [Improved pulses / Decreased pressure / Improved cap refill / Other] Post-procedure: Sterile dressing applied; patient monitored for return of compartment symptoms Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Infection / Other] Total time: [ ] minutes

Nasal Foreign Body Removal Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: Foreign body in nostril Side: [Right / Left] Foreign body type: [Metal / Organic / Plastic / Other] Anesthesia: [None / Topical 1% lidocaine / Other] Preparation: Sterile technique with gloves and instruments used Method of removal: [Forceps / Suction / Positive pressure / Katz extractor / Balloon catheter / Other] Number of attempts: [ ] Result: [Foreign body completely removed / Partial removal / Unsuccessful] Post-procedure: Patient monitored for complications; advised on follow-up if symptoms worsen Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Mucosal injury / Other] Total time: [ ] minutes

Dental Block Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: [Dental pain / Fractured tooth / Dental abscess / Other] Side: [Right / Left] [Upper / Lower] Anesthesia: [1% lidocaine / 2% lidocaine with epinephrine / Bupivacaine / Other] Technique: [Inferior alveolar nerve block / Mental nerve block / Maxillary nerve block / Other] Number of attempts: [ ] Effectiveness: [Pain relief achieved / Partial relief / No relief] Post-procedure: Patient advised to avoid biting or chewing on anesthetized side; follow-up with dentist recommended Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Nerve injury / Other] Total time: [ ] minutes

Reduction of Paraphimosis Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: Paraphimosis Anesthesia: [None / Local 1% lidocaine [ ] mL / Other] Method: [Manual reduction with lubrication and gentle compression / Osmotic technique with sugar / Ice application / Other] Number of attempts: [ ] Post-reduction exam: [Foreskin returned to normal position / Swelling reduced / Improved circulation / Persistent swelling] Complications: [None / Pain / Bleeding / Persistent swelling / Other] Post-procedure: Patient advised on hygiene, to avoid retraction of foreskin, and follow-up with urology recommended Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Penile Block Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: [Circumcision / Genital trauma / Pain management for penile procedure / Other] Anesthesia: [1% lidocaine without epinephrine / Bupivacaine / Other] Technique: [Dorsal nerve block / Ring block / Other] Number of attempts: [ ] Effectiveness: [Complete pain relief / Partial relief / No relief] Complications: [None / Bleeding / Infection / Nerve injury / Other] Post-procedure: Patient advised on post-procedure care and follow-up if symptoms persist Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Peritonsillar Abscess Drainage Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: Peritonsillar abscess Side: [Right / Left] Anesthesia: [Local 1% lidocaine [ ] mL / Topical anesthetic spray / Other] Preparation: Sterile technique with gloves and instruments used Procedure: - Incision made with [Scalpel #11 / Needle aspiration / Other] - Amount of pus drained: [Small / Moderate / Large / [ ] mL] - Culture obtained: [Yes / No] Complications: [None / Bleeding / Aspiration / Other] Post-procedure: Patient advised on post-drainage care; antibiotics prescribed; follow-up with ENT arranged Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Manual Placenta Removal Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Unable to obtain – emergent] Indication: [Retained placenta / Postpartum hemorrhage / Other] Anesthesia: [None / Local 1% lidocaine [ ] mL / Sedation / Other] Preparation: Sterile technique with gloves, gown, and drape applied Method: [Manual removal of retained placenta with gentle traction / Other] Placenta removed in: [Intact / Fragmented pieces] Estimated blood loss: [ ] mL Uterine tone post-removal: [Firm / Boggy / Other] Complications: [None / Uterine atony / Hemorrhage / Other] Post-procedure: Fundal massage performed; oxytocin administered; patient monitored for ongoing hemorrhage Patient tolerated: [Well / Poorly] Total time: [ ] minutes

NG Tube Placement Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: [Bowel obstruction / Gastric decompression / Aspiration of gastric contents / Other] Anesthesia: [None / Topical anesthetic spray / Other] Technique: NG tube inserted through nasal passage and advanced into stomach under direct visualization Tube size: [ ] French Number of attempts: [ ] Confirmation of placement: [Aspiration of gastric contents / Auscultation over epigastrium / Chest X-ray / Other] Post-procedure: Tube secured; patient monitored; instructions provided for continued use Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Nasal trauma / Malposition / Other] Total time: [ ] minutes

Suprapubic Catheter Insertion Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Guardian / Unable to obtain – emergent] Indication: [Urinary retention / Urethral injury / Long-term catheterization / Other] Anesthesia: [Local 1% lidocaine [ ] mL / Sedation / Other] Preparation: Sterile technique with [Chlorhexidine / Betadine / Other]; sterile gown, gloves, and drape applied Catheter size: [ ] French suprapubic catheter Technique: Needle and catheter introduced through lower abdomen into bladder Confirmation of placement: [Aspiration of urine / Ultrasound / Other] Post-procedure: Catheter secured; urine bag attached; patient monitored Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Infection / Bowel perforation / Other] Total time: [ ] minutes

Burn Carer (Debribement and Dressing) Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Emergent – unable to obtain] Indication: [Partial-thickness burn / Full-thickness burn / Other] Location: [Right / Left / Bilateral] [ ] Size of burn: [ ] cm² / % TBSA Anesthesia: [None / Local 1% lidocaine [ ] mL / Other] Preparation: Sterile technique with gloves, gown, and drape applied Debridement: [Minimal / Moderate / Extensive] Type of debridement: [Sharp / Mechanical / Enzymatic / Other] Tissue removed: [Necrotic / Infected / Other] Dressing applied: [Silver sulfadiazine / Bacitracin / Mepilex / Other] Post-procedure: Wound covered with sterile dressing; patient instructed on burn care and follow-up Complications: [None / Bleeding / Infection / Other] Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Burn Care (Escharotomy and Dressing) Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Unable to obtain – emergent] Indication: [Full-thickness circumferential burn / Compartment syndrome / Other] Site: [Right / Left / Bilateral] [Upper limb / Lower limb / Chest / Other] Preparation: Sterile technique with [Chlorhexidine / Betadine / Other]; sterile gloves and drape applied Anesthesia: [None / Local 1% lidocaine [ ] mL / Other] Procedure: - Incision made along length of eschar down to subcutaneous tissue - Number of incisions: [ ] - Circulation improved: [Yes / No] - Post-procedure dressing applied: [Sterile gauze / Other] Post-procedure: Patient reassessed for compartment pressure relief and circulation Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Infection / Other] Total time: [ ] minutes

Lateral Canthotomy Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Unable to obtain – emergent] Indication: [Orbital compartment syndrome / Retrobulbar hemorrhage / Other] Site: [Right / Left] eye, lateral canthus Preparation: Sterile technique with [Chlorhexidine / Betadine / Other]; sterile gloves applied Anesthesia: [None / Local 1% lidocaine [ ] mL / Other] Procedure: - Lateral canthal tendon incised - Immediate decompression and pressure relief observed - Number of attempts: [ ] Intraocular pressure pre-procedure: [ ] mmHg Intraocular pressure post-procedure: [ ] mmHg Complications: [None / Bleeding / Infection / Other] Post-procedure: Patient reassessed; eye swelling and orbital pressure [Improved / Not improved] Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Local/Regional Anesthesia Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Time-out Consent: [Verbal / Written / Guardian / Parent / Emergent – unable to obtain] Indication: [Laceration repair / Fracture reduction / Incision & drainage / Other] Monitoring: [None / Cardiac / Blood pressure / Pulse oximetry] Preparation: [Suction / IV access / Constant attendance / Supplemental O₂ / Not applicable] ASA class: [I Healthy / II Mild systemic disease / III Severe systemic disease, non-life-threatening / IV Severe systemic disease, life-threatening / V Moribund, not expected to survive 24 hrs] Mallampati score: [I Full soft palate / II Most of uvula visible / III Base of uvula visible / IV Only hard palate visible] Physical exam: [See physical exam] Pre-anesthesia vitals: [See nursing documentation] Anesthesia type: [Local / Regional] Medication: [Lidocaine / Lidocaine with epinephrine / Bupivacaine / Other] Route: [Local infiltration / Nerve block / Other] Dose: [ ] mL Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Infection / Allergic reaction / Other] Total intraservice time: [ ] minutes Notes: Procedure performed without complications. Patient monitored for adverse reactions; none observed.

Nerve Block Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Time-out Consent: [Verbal / Written / Guardian / Parent / Emergent – unable to obtain] Indication: [Pain control for fracture reduction / Laceration repair / Post-procedure pain / Other] Monitoring: [None / Cardiac / Blood pressure / Pulse oximetry] Preparation: [Suction / IV access / Constant attendance / Supplemental O₂ / Not applicable] ASA class: [I Healthy / II Mild systemic disease / III Severe systemic disease, non-life-threatening / IV Severe systemic disease, life-threatening / V Moribund, not expected to survive 24 hrs] Mallampati score: [I Full soft palate / II Most of uvula visible / III Base of uvula visible / IV Only hard palate visible] Physical exam: [See physical exam] Pre-block vitals: [See nursing documentation] Nerve block administered: [Digital block / Penile block / Femoral block / Other] Medication: [Lidocaine / Lidocaine with epinephrine / Bupivacaine / Other] Dose: [ ] mL Route: [Local infiltration / Other] Patient tolerated: [Well / Poorly] Complications: [None / Bleeding / Infection / Allergic reaction / Other] Total intraservice time: [ ] minutes Notes: Procedure performed without complications. Patient monitored for adverse reactions; none observed.

Intranasal Sedation Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Time-out Consent: [Verbal / Written / Guardian / Parent / Emergent – unable to obtain] Indication: [Laceration repair / Fracture reduction / Pain control / Other] Monitoring: Continuous cardiac, blood pressure, and pulse oximetry Preparation: [Suction / IV access / Constant attendance / Supplemental O₂ / Not applicable] ASA class: [I Healthy / II Mild systemic disease / III Severe systemic disease, non-life-threatening / IV Severe systemic disease, life-threatening / V Moribund, not expected to survive 24 hrs] Mallampati score: [I Full soft palate / II Most of uvula visible / III Base of uvula visible / IV Only hard palate visible] Physical exam: [See physical exam] Pre-sedation vitals: [See nursing documentation] Medication administered intranasally: [Ketamine / Midazolam / Fentanyl / Other] Dose: [ ] mg/mcg Route: Intranasal Patient tolerated: [Well / Poorly] Complications: [None / Hypoxia / Hypotension / Bradycardia / Other] Total intraservice time: [ ] minutes Notes: Procedure performed without complications. Patient monitored for adverse reactions; none observed.

Rectal Prolapse Reduction Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Unable to obtain – emergent] Indication: Rectal prolapse Procedure: - Patient positioned: [Lithotomy / Prone / Other] - Prolapsed rectal tissue cleansed and lubricated - Manual reduction performed with gentle pressure using gauze and lubrication Reduction successful: [Yes / No / Partial] Post-reduction exam: [Good perfusion / Swelling / Tissue necrosis / Other] Dressing applied: [Moist gauze / None / Other] Complications: [None / Recurrence / Strangulation / Other] Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Vaginal Prolapse Reduction Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Unable to obtain – emergent] Indication: Vaginal prolapse Procedure: - Patient positioned: Lithotomy - Prolapsed vaginal tissue cleansed and lubricated - Manual reduction performed with gentle pressure using gauze and lubrication Reduction successful: [Yes / No / Partial] Post-reduction exam: [Good perfusion / Swelling / Tissue necrosis / Other] Dressing applied: [Moist gauze / None / Other] Complications: [None / Recurrence / Strangulation / Other] Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Fracture Care (Splinting/Reduction) Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Unable to obtain – emergent] Indication: Fracture of [ ] confirmed by X-ray Type of fracture: [Closed / Open] Location: [Proximal / Mid-shaft / Distal] Laterality: [Right / Left] Pre-procedure neurovascular exam: [Intact / Circulation deficit / Sensory deficit / Motor deficit] Anesthesia: [None / Local 1% lidocaine [ ] mL / Sedation / Other] Reduction: [Successful / Unsuccessful] Number of attempts: [ ] Method: [Closed reduction / Traction / Manipulation / Other] Splint applied: [Yes / No] Type of splint: [Sugar tong / U-slab / Short arm / Long arm / Short leg / Long leg / Thumb spica / Other] Post-reduction X-ray: [Confirmed reduction / Malalignment / Other] Post-procedure neurovascular exam: [Intact / Circulation deficit / Sensory deficit / Motor deficit] Complications: [None / Other] Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Intraosseous Line Placement Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Site / Time-out Consent: [Unable to obtain – emergent / Verbal / Written] Indication: [Shock / Cardiac arrest / Unable to obtain IV access / Other] Site: [Right / Left] [Proximal tibia / Distal tibia / Proximal humerus / Other] Needle size: [15G / 18G / Other] Procedure: IO needle inserted using [Drill / Manual technique]; aspiration confirmed; line flushed with saline Number of attempts: [ ] Confirmation: [Aspiration of marrow / Easy flush / Stable position] Complications: [None / Extravasation / Infection / Fracture / Other] Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Defibrillation Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Time-out Consent: Unable to obtain – emergent Indication: [Ventricular fibrillation / Pulseless VTach / Other] Pads: [Anterior-posterior / Anterior-lateral] Energy delivered: [ ] Joules Number of shocks: [ ] Rhythm post-defibrillation: [NSR / Persistent VF/VT / Other] Complications: [None / Arrhythmia / Skin burn / Other] Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Ear Foreign Body Removal Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Unable to obtain] Indication: Foreign body in ear canal Side: [Right / Left] Type of foreign body: [Insect / Bead / Toy / Organic material / Other] Method: [Forceps / Irrigation / Suction / Curette / Other] Number of attempts: [ ] Result: [Foreign body completely removed / Partial removal / Unsuccessful] Complications: [None / Bleeding / TM perforation / Canal trauma / Other] Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Cerumen Removal Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian] Indication: Impacted cerumen with decreased hearing / Otalgia / Obstructed exam / Other Side: [Right / Left / Bilateral] Method: [Irrigation / Curette / Suction / Other] Number of attempts: [ ] Result: [Complete removal / Partial removal / Unable to remove] Complications: [None / Canal trauma / TM perforation / Bleeding / Other] Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Eye Irrigation Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Side / Site / Time-out Consent: [Verbal / Written / Guardian / Unable to obtain] Indication: [Chemical exposure / Foreign body / Corneal abrasion / Other] Eye: [Right / Left / Bilateral] Preparation: Morgan lens placed with topical anesthetic; IV tubing connected to NS/LR Volume irrigated: [ ] L End-point: [pH normalized / Debris cleared / Other] Complications: [None / Corneal abrasion / Persistent foreign body sensation / Other] Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Straight Catheterization/Bladder Scan Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Site / Time-out Consent: [Verbal / Written / Guardian / Unable to obtain] Indication: [Urinary retention / Incontinence / Obtain sterile urine specimen / Other] Preparation: Sterile technique with [Chlorhexidine / Betadine / Other]; sterile gloves and drape Catheter size: [ ] French straight catheter Number of attempts: [ ] Urine obtained: [ ] mL – [Clear / Cloudy / Bloody / Other] Bladder scan: [Performed / Not performed] – Residual volume [ ] mL Complications: [None / Urethral trauma / Infection / Other] Patient tolerated: [Well / Poorly] Total time: [ ] minutes

MDM

Sepsis Note Time zero (Severe Sepsis): [ ] Classification: [Sepsis / Severe Sepsis / Septic Shock] If Severe Sepsis → criteria met: [Lactate >2.0 / SBP <90 / MAP 2.0 / Bili >2.0 / Platelets 1.5 / PTT >60] If Septic Shock → criteria met: [Lactate ≥4.0 / Hypotension despite fluids] Cultures and antibiotics: Blood cultures obtained prior to broad-spectrum IV antibiotics. → See MAR/nursing documentation for exact times and agents administered. Lactate: Initial [ ] mmol/L (see lab record for time). Repeat lactate obtained (see lab record for time). Fluids: Crystalloid bolus given per IBW (~30 mL/kg, IBW = [ ] kg). → Total given: [ ] mL (see nursing documentation for exact volume/timing). → Alternative volume [ ] mL given due to [renal / cardiac / other concern]. Reperfusion reassessment: I have reassessed the patient’s hemodynamic status and tissue perfusion after the fluid bolus. Findings: [MAP adequate / BP stable / Mental status intact / Urine output adequate]. See nursing documentation for full vitals. Performed by: [Myself / Resident / PA] Notes: SEP-1 sepsis bundle elements completed as documented above and in MAR/nursing flowsheets. Cultures pending.

Critical Care Note Total time: [35 / 35–75 / 104 / Other: ] minutes (Exclusive of procedure time and separate from teaching time) Impending deterioration: [Airway / Respiratory / Cardiovascular / CNS / Metabolic / Renal] Associated risk factors: [Hypotension / Shock / Hypoxia / Bleeding / Trauma / Dysrhythmia / Metabolic changes / Dehydration / Acidosis / Hypertension / Overdose / Other] Management: Bedside assessment and supervision of care Performed by: [Myself / Resident / PA] Notes: Patient had a high probability of imminent, life-threatening deterioration requiring direct attention, intervention, and personal management. Critical care time excludes separately billable procedures. Time includes review of labs, radiology results, discussion with consultants, and close monitoring for decompensation. Medical decision-making was of high complexity, involving assessment, manipulation, and support of vital system functions to treat single or multiple organ system failure and/or to prevent further deterioration. Interventions performed as documented.

Restraint Application Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Procedure / Time-out Consent: Unable to obtain – emergent Indication: [Danger to self / Danger to others / Severe agitation / Other] Type of restraint: [Soft wrist / Soft ankle / Four-point / Vest / Other] Monitoring: Patient monitored per hospital protocol Complications: [None / Skin breakdown / Bruising / Other] Post-procedure: Circulation, motor, sensory [Intact / Deficit]; patient reassessed regularly Patient tolerated: [Well / Poorly] Total time: [ ] minutes

Stroke Protocol Note The patient presents with symptoms concerning for an acute stroke. Initial Assessment: - Last known well: [ ] - NIHSS score: [ ] - Head CT: [Normal / Abnormal / Pending] Thrombolytic Evaluation: - tPA eligibility determined: [Yes / No] - Contraindications: [None / Present – specify] - tPA administered at [ ] — Dose: [ ] mg - If not given, reason: [Outside window / Contraindications / Other] Medications Administered: - Antiplatelet: [Aspirin [ ] mg / Other] - Other: [ ] Consultation: - Neurology consulted at [ ] - Plan discussed: [Admit ICU / Admit stroke unit / Other] Patient Reassessment: - BP: [ ] - HR: [ ] - Neuro status: [Improved / Worsening / No change] Complications: [None / Symptomatic ICH / Hypotension / Other] Disposition: Admit to [ICU / Stroke unit / Other] for further management

Postmortem Care and Documentation Note Time of death: [ ] Confirmed: Patient identity, date, and time Pronounced by: [Myself / Resident / PA / Other provider] Family notified: [Yes / No] Cause of death: [ ] Medical examiner notified: [Yes / No / Not applicable] Autopsy: [Requested / Declined by family / Not indicated] Death certificate: [Completed / Pending] Postmortem care: - Lines and tubes removed: [Yes / No] - Body prepared for transport to [Morgue / Funeral home / Other] - Personal belongings: [Secured and given to family / Transported with body] - Organ donation discussed: [Yes / No / N/A] Complications: [None / Other] Performed by: [Myself / Resident / PA / Other] Total time: [ ] minutes

DNR Discussion and Documentation Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Family / Legal guardian / Time / Date Discussion held with: [Patient / Family / Legal guardian / Other] Indication for DNR: [Terminal illness / Poor prognosis / Patient request / Other] DNR status confirmed: [Yes / No] Specifics of DNR: [No CPR / No intubation / No defibrillation / Other limitations] Family understanding: [Full / Partial / Further clarification needed] Decision support: [Palliative care team / Social worker / Chaplain / None / Other] Complications: [None / Conflict / Other] DNR documentation: [Completed and signed / Pending / Not completed] Total time: [ ] minutes

Withholding/Withdrawal of Care Note Time: [ ] Performed by: [Myself / Resident / PA / Other] Confirmed: Patient / Family / Legal guardian / Time / Date Discussion held with: [Patient / Family / Legal guardian / Other] Indication: [Terminal illness / Poor prognosis / Patient request / Other] Care withheld/withdrawn: [Mechanical ventilation / CPR / Pressors / Feeding tubes / Dialysis / Other] Family understanding: [Full / Partial / Further clarification needed] Decision support: [Palliative care team / Social worker / Chaplain / None / Other] Complications: [None / Conflict / Other] Documentation: [Completed / Pending / Not completed] Total time: [ ] minutes

AMA (Against Medical Advice) Note This patient has elected to LEAVE AGAINST MEDICAL ADVICE (AMA). Capacity Assessment: - Patient awake, alert, clinically sober, oriented, and free from distracting injury - Demonstrates intact insight, judgment, and reasoning capacity - Patient is able to understand and verbalize risks and alternatives - No evidence of suicidal ideation, worsening depression, or impaired decision-making capacity Risks Explained: I explained that leaving may result in: [Death / Permanent disability / Serious injury / Worsening condition / Other] Patient verbalized understanding of these risks. Alternatives Offered: [Admission / Observation / Alternate diagnostic workup / Treatment / Other] Patient refused these alternatives and continued to request discharge. Course: - Patient refuses any further testing or treatment - Patient understands risks up to and including death and permanent disability - Patient invited to return at any time for evaluation or care - Encouraged to return immediately if symptoms worsen or patient changes mind Documentation: - Patient signed AMA form: [Yes / No / Refused] - Witness present: [Yes / No] Performed by: [Myself / Resident / PA / Other]

Clinical Decision Calculators

HEART Score

Link to MDCalc HEART Score

Link to MDCalc HEART Pathway

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. The HEART score helps assess the risk of major adverse cardiac events (MACE) in patients presenting with chest pain. It guides decision-making regarding admission or discharge. HEART Score is a standalone tool focused on providing an immediate risk assessment based on a single set of variables. HEART Pathway takes it a step further by incorporating serial troponin testing to guide further decision-making, especially in low-risk patients, and reduce unnecessary admissions and diagnostic testing.

NIHSS (National Institutes of Health Stroke Scale)

Link to MDCalc NIHSS

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. The NIHSS assesses the severity of stroke and is commonly used in acute stroke management.

Wells' Criteria for DVT

Link to MDCalc Wells' Criteria for DVT

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. The Wells Criteria for DVT helps estimate the probability of deep vein thrombosis (DVT) based on clinical signs, symptoms, and risk factors. It guides decision-making on whether to pursue further diagnostic testing, such as D-dimer or ultrasound, based on the patient’s risk category.The Wells Criteria for DVT helps estimate the probability of deep vein thrombosis (DVT) based on clinical signs, symptoms, and risk factors. It guides decision-making on whether to pursue further diagnostic testing, such as D-dimer or ultrasound, based on the patient’s risk category. The HEART score helps assess the risk of major adverse cardiac events (MACE) in patients presenting with chest pain. It guides decision-making regarding admission or discharge. HEART Score is a standalone tool focused on providing an immediate risk assessment based on a single set of variables. HEART Pathway takes it a step further by incorporating serial troponin testing to guide further decision-making, especially in low-risk patients, and reduce unnecessary admissions and diagnostic testing.

Wells Criteria for Pulmonary Embolism

Link to MDCalc Wells' Criteria

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. This tool estimates the probability of pulmonary embolism (PE) in patients. It helps determine whether further diagnostic tests like a D-dimer or CT scan are needed.

PERC Rule

Link to MDCalc PERC Rules

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. The PERC rule helps rule out PE in low-risk patients without further testing, reducing unnecessary imaging.

PSI/PORT (Pneumonia Severity Index)

Link to MDCalc PSI/PORT

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. This tool helps determine the severity of pneumonia and guides whether a patient should be treated as an inpatient or outpatient.

CURB-65 Score

Link to MDCalc CURB-65

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. The CURB-65 score is used to assess the severity of pneumonia and determine if hospitalization is necessary. The PERC rule helps rule out PE in low-risk patients without further testing, reducing unnecessary imaging.

Glasgow-Blatchford Score (GBS)

Link to MDCalc Glasgow-Blatchford Score

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. The GBS assesses the severity of upper GI bleeding and helps guide decisions on urgent interventions like endoscopy.

CHA₂DS₂-VASc Score

Link to MDCalc CHA₂DS₂-VASc Score

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. The CHA₂DS₂-VASc Score estimates the risk of stroke in patients with atrial fibrillation. It helps guide decisions regarding anticoagulation therapy in these patients.

ABCD² Score

Link to MDCalc ABCD² Score

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. The ABCD² Score estimates the risk of stroke in patients presenting with transient ischemic attack (TIA) by assessing five key factors. It helps determine the need for hospitalization and further intervention.

PECARN (Pediatric Emergency Care Applied Research Network)

Link to MDCalc PECARN

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. This rule assists in deciding whether children with head trauma require a head CT.

NEXUS Criteria for C-Spine Imaging

Link to MDCalc NEXUS Criteria

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. The NEXUS Criteria help determine whether cervical spine imaging is necessary in trauma patients. It identifies low-risk patients who do not require imaging based on specific criteria like the absence of tenderness, intoxication, and neurological deficits.

NEXUS Head CT Rule

Link to MDCalc NEXUS Head CT Rule

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. The NEXUS Head CT Rule helps determine the need for head CT imaging in patients with blunt head trauma. It identifies low-risk patients who can safely avoid imaging based on clinical criteria like GCS, signs of skull fracture, and neurological findings.

Canadian CT Head Rule

Link to MDCalc Canadian CT Head Rule

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. The Canadian CT Head Rule helps determine whether a head CT is necessary in patients with minor head injury. It identifies patients at risk of serious head injury based on specific criteria like GCS, signs of skull fracture, and high-risk mechanisms of injury.

Glasgow Coma Scale (GCS)

Link to MDCalc Glasgow Coma Scale

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. The Glasgow Coma Scale (GCS) assesses a patient’s level of consciousness in trauma or critically ill patients by scoring eye, verbal, and motor responses. It is commonly used to determine the severity of head injury.

SIRS, Sepsis, and Septic Shock Criteria

Link to MDCalc Canadian CT Head Rule

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. The SIRS, Sepsis, and Septic Shock Criteria help identify and manage patients with sepsis and septic shock by using a combination of vital signs and clinical symptoms. This tool is critical in the early recognition and treatment of sepsis to reduce mortality.

qSOFA (Quick SOFA) Score

Link to MDCalc qSOFA Score

Note: If you log into MDCalc, you can copy the results of the score and add them to your note. The qSOFA Score (Quick Sequential Organ Failure Assessment) is used to quickly identify patients with suspected infection who are at higher risk of poor outcomes, including sepsis. It uses three simple criteria: altered mental status, respiratory rate ≥ 22, and systolic blood pressure ≤ 100 mmHg.

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