What is a Procedure Note?

A procedure note is a documentation of a medical procedure which is added to a patient's chart after the procedure has been completed. Procedure notes are important because they clearly indicate which procedures have been performed on a patient, when they were performed, and what the results of these procedures were. In addition, they protect hospitals and doctors from legal repercussions by clearly and concisely recording relevant data about procedures. In some cases, procedure note templates may be used to ensure uniformity.

Several pieces of information are contained in a procedure note. The name of the doctor performing the procedure and anyone else present is always included, along with detailed information about the procedure. Rather than just stating that an intravenous catheter was placed, for example, the note will say where, when, why, and how. The procedure note also includes information about anesthetics used during the procedure, and it also usually includes a note that sterile materials and protocol were utilized. Finally, a procedure note also includes a section stating that informed consent was obtained from the patient, unless the procedure was performed during a life threatening emergency.

Along with the other information in a patient's chart, procedure notes help to form a complete picture of how the patient is doing, medically. Any medical professional should be able to pick up the chart and know everything about the patient's case, from the drugs that the patient is on to everything that has been done to identify the patient's condition and treat it. Procedure notes can also be useful, because doctors will note findings and complications, alerting other medical personnel to issues which should be addressed.

The format for procedure notes is fairly standard, and it is included in the training for most medical careers. Schools which specialize in medical education want to make sure that their graduates are capable of offering quality health care and that they can document their work clearly and in a format which can stand up in court, if necessary. Although the primary focus of a procedure note is improving overall patient care, the legal protections are usually considered when medical personnel write out such notes, just to be on the safe side.

For patients, procedure notes may seem rather confusing, because they often use complex medical terminology or abbreviations. Patients do have a right to look at their medical charts, and if they are curious about anything in their charts, they can consult a doctor or medical professional for a clear explanation of any confusing information. In most countries, patients may also petition to correct inaccuracies in their charts, including inaccuracies in procedure notes.