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 st
