Procedure Note Template

Overview

Generate pre-populated procedure documentation templates from FHIR data. Pull patient demographics, procedure indication from active conditions, relevant pre-procedure labs (coagulation studies, platelets, hemoglobin), allergy list, and current anticoagulant status. Include required elements: informed consent verification, time-out documentation, procedure details, specimen handling, complications, and post-procedure orders. Support common bedside procedures: central venous catheter, arterial line, intubation, lumbar puncture, paracentesis, thoracentesis, chest tube, foley catheter, and NG tube.

FHIR Resources Used

Instructions

Step 1: Retrieve Patient Demographics

Tool: fhir_read
resourceType: "Patient"
id: "[patient-id]"

Extract: name, DOB, age, gender, MRN for procedure note header and patient identification band verification.

Step 2: Identify Procedure Indication

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&clinical-status=active"

Match the stated procedure to an active condition as the indication. Common mappings:

• Central line: difficult IV access, need for vasopressors, TPN, prolonged IV antibiotics
• Arterial line: hemodynamic instability, frequent ABG monitoring
• Intubation: respiratory failure, airway protection
• Lumbar puncture: meningitis workup, subarachnoid hemorrhage evaluation
• Paracentesis: ascites (tense, diagnostic)
• Thoracentesis: pleural effusion (diagnostic or therapeutic)
• Chest tube: pneumothorax, hemothorax, empyema
• Foley catheter: urinary retention, strict I&O monitoring, perioperative
• NG tube: bowel obstruction, GI decompression, medication administration

Step 3: Pull Pre-Procedure Labs

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=laboratory&code=http://loinc.org|5902-2,http://loinc.org|6301-6,http://loinc.org|777-3,http://loinc.org|718-7,http://loinc.org|3173-2&_sort=-date&_count=20"

Critical pre-procedure LOINC codes:

• 5902-2: PT (Prothrombin time)
• 6301-6: INR
• 3173-2: aPTT (Activated partial thromboplastin time)
• 777-3: Platelet count
• 718-7: Hemoglobin
• 4544-3: Hematocrit

Flag if:

• INR > 1.5 (relative contraindication for most invasive procedures)
• Platelets < 50,000 (increased bleeding risk)
• Platelets < 20,000 (contraindication without transfusion)
• aPTT > 1.5x control
• Hemoglobin < 7 (consider transfusion before elective procedure)
• Labs > 24 hours old (recommend recheck)

Step 4: Check Allergies

Tool: fhir_search
resourceType: "AllergyIntolerance"
queryParams: "patient=[patient-id]&clinical-status=active"

Flag procedure-relevant allergies:

• Latex: Use non-latex gloves, equipment
• Iodine/Betadine: Use chlorhexidine for skin prep
• Chlorhexidine: Use betadine for skin prep
• Lidocaine/local anesthetics: Use alternative anesthetic, allergy consult
• Adhesive/tape: Use alternative securement
• Heparin (HIT): Avoid heparin-coated catheters and flushes

Step 5: Check Anticoagulant Status

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=active&category=http://terminology.hl7.org/CodeSystem/medicationrequest-category|inpatient"

Check active medications for anticoagulants and antiplatelets:

• Heparin drip: Check if held, last aPTT value
• Enoxaparin: Timing of last dose (hold 12h for prophylactic, 24h for therapeutic)
• Warfarin: Current INR
• DOACs (apixaban, rivarelbán, edoxaban): Timing of last dose (hold 24-48h)
• Clopidogrel, prasugrel, ticagrelor: Document if held
• Aspirin: Generally continued for most bedside procedures

Step 6: Check Consent Status

Tool: fhir_search
resourceType: "Consent"
queryParams: "patient=[patient-id]&status=active&scope=treatment"

If no procedure-specific consent found, flag: "INFORMED CONSENT: NOT DOCUMENTED -- obtain before proceeding."

Step 7: Pull Pre-Procedure Vitals

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=vital-signs&_sort=-date&_count=10"

Document baseline vitals before procedure.

Step 8: Assemble Procedure Note Template

PROCEDURE NOTE
===============
Patient: [name] | MRN: [mrn] | DOB: [dob] (Age: [age]) | Sex: [gender]
Date/Time: [procedure datetime]
Procedure: [procedure name]
Operator: [Flag: "Enter operator name and credentials"]
Supervising Physician: [if applicable]
Service: [service]

INDICATION
----------
[Condition from Step 2 with ICD-10 code]

INFORMED CONSENT
----------------
[Consent status from Step 6]
Risks, benefits, and alternatives discussed with: [patient / surrogate]
Consent signed: [date/time or "REQUIRED"]

ALLERGIES
---------
[List with procedure-relevant flags]

PRE-PROCEDURE VERIFICATION (TIME-OUT)
--------------------------------------
- [ ] Correct patient (two-identifier verification)
- [ ] Correct procedure confirmed
- [ ] Correct site/laterality marked (if applicable)
- [ ] Informed consent obtained
- [ ] Relevant labs reviewed:
      PT/INR: [value] ([date]) [FLAG if abnormal]
      Platelets: [value] ([date]) [FLAG if abnormal]
      Hemoglobin: [value] ([date]) [FLAG if abnormal]
      aPTT: [value] ([date]) [FLAG if abnormal]
- [ ] Anticoagulant status: [status from Step 5]
- [ ] Allergies reviewed: [summary]
- [ ] Equipment and supplies verified

PRE-PROCEDURE VITALS
---------------------
HR: [hr] | BP: [sys]/[dia] | RR: [rr] | SpO2: [spo2]% on [O2]

SEDATION / ANESTHESIA
----------------------
[Flag: "Complete if conscious sedation used"]
Sedation type: [none / local only / moderate sedation / deep sedation]
Medications administered:
  - [Drug] [dose] [route] [time] [Flag: "Enter"]
  - [Drug] [dose] [route] [time] [Flag: "Enter"]
Pre-sedation assessment: ASA class [I-V], Mallampati [I-IV], NPO status [hours]
Monitoring: Continuous pulse oximetry, cardiac monitor, ETCO2 (if applicable)

PROCEDURE DETAILS
-----------------
[Flag: "Operator to complete procedure details"]
Position: [supine / lateral decubitus / sitting / Trendelenburg]
Skin prep: [chlorhexidine / betadine] [Note allergy-based selection]
Draping: Sterile draping applied
Anesthesia: [lidocaine X% / bupivacaine X%] [volume] mL infiltrated to [site]
Technique: [Description of procedure steps]
Site: [anatomical location, laterality]

[Procedure-specific fields -- see references/procedure-documentation.md]

SPECIMENS
---------
[If applicable]
Type: [fluid / tissue / culture]
Sent to: [lab / microbiology / cytology / pathology]
Tests ordered: [cell count, culture, protein, glucose, LDH, cytology, etc.]
Labeled: [Yes -- two-identifier verification]

ESTIMATED BLOOD LOSS
--------------------
[volume] mL

COMPLICATIONS
-------------
[None / describe]
[Procedure-specific complication checklist -- see references/procedure-safety.md]

POST-PROCEDURE
--------------
Patient tolerated procedure: [well / with complications]
Post-procedure vitals: HR [hr] | BP [sys]/[dia] | SpO2 [spo2]%
Post-procedure imaging ordered: [CXR for central line/chest tube / none]
Post-procedure orders:
  - [Site check q[interval]]
  - [Dressing change instructions]
  - [Activity restrictions]
  - [Lab follow-up]

DISPOSITION
-----------
Patient returned to: [floor / ICU / recovery]
Attending notified: [Yes/No]

Step 9: Create Procedure Resource in FHIR

Tool: fhir_create
resourceType: "Procedure"
resource: {
  "resourceType": "Procedure",
  "status": "completed",
  "code": {
    "coding": [{
      "system": "http://www.ama-assn.org/go/cpt",
      "code": "[CPT-code]",
      "display": "[procedure-name]"
    }]
  },
  "subject": {"reference": "Patient/[patient-id]"},
  "encounter": {"reference": "Encounter/[encounter-id]"},
  "performedDateTime": "[procedure-datetime]",
  "performer": [{
    "actor": {"reference": "Practitioner/[practitioner-id]"}
  }],
  "reasonReference": [{"reference": "Condition/[indication-condition-id]"}],
  "outcome": {
    "coding": [{
      "system": "http://snomed.info/sct",
      "code": "385669000",
      "display": "Successful"
    }]
  },
  "note": [{"text": "[brief procedure summary]"}]
}

Common CPT codes:

• 36556: Central venous catheter insertion (non-tunneled)
• 36620: Arterial line insertion
• 31500: Intubation, endotracheal
• 62270: Lumbar puncture
• 49083: Paracentesis
• 32555: Thoracentesis
• 32551: Chest tube insertion
• 51702: Foley catheter insertion
• 43752: NG tube insertion

Examples

Example 1: Central Line Placement

User says: "Procedure note for central line placement on patient 11111."

Actions:

1. fhir_read Patient/11111. Returns: James Torres, DOB 1955-06-30, Male, MRN-11111.
2. fhir_search Condition active. Returns: Septic shock (R65.21), pneumonia (J18.9), T2DM, CKD4.
3. fhir_search Observation labs (coags, CBC). Returns: INR 1.2, platelets 188k, Hgb 9.8, aPTT 28.
4. fhir_search AllergyIntolerance. Returns: Latex allergy (urticaria). Flag: USE NON-LATEX EQUIPMENT.
5. fhir_search MedicationRequest anticoagulants. Returns: Heparin drip active -- held 2 hours ago, aPTT at hold was 55.
6. fhir_search Observation vitals. Returns: HR 105, BP 88/52 on norepinephrine, SpO2 96% on 4L NC.

Result:

PROCEDURE NOTE
===============
Patient: James Torres | MRN: MRN-11111 | DOB: 1955-06-30 (Age: 68) | Sex: Male
Procedure: Central venous catheter insertion (non-tunneled)

INDICATION: Septic shock requiring vasopressor administration (R65.21)

ALLERGIES
** LATEX ALLERGY (urticaria) -- USE NON-LATEX GLOVES AND EQUIPMENT **

PRE-PROCEDURE VERIFICATION
- Labs: INR 1.2 [OK] | Platelets 188k [OK] | Hgb 9.8 [OK] | aPTT 28 [OK]
- Anticoagulant: Heparin drip HELD 2h ago, aPTT at hold: 55
- Consent: [VERIFY]

PRE-PROCEDURE VITALS
HR: 105 | BP: 88/52 (on norepinephrine) | SpO2: 96% on 4L NC

[Procedure details: operator to complete -- site, technique, number of attempts,
 catheter type/size, line placement confirmation method, post-procedure CXR ordered]

Example 2: Lumbar Puncture

User says: "Generate LP procedure note template for patient pt-222, meningitis workup."

Actions:

1. fhir_read Patient/pt-222. Returns: Emily Park, DOB 1990-03-22, Female.
2. fhir_search Condition. Returns: Fever of unknown origin (R50.9), headache (R51.9), nuchal rigidity (R29.1).
3. fhir_search Observation labs. Returns: INR 1.0, platelets 245k, Hgb 12.8, WBC 18.5.
4. fhir_search AllergyIntolerance. Returns: NKDA.
5. fhir_search MedicationRequest. Returns: No anticoagulants active.
6. fhir_search Observation vitals. Returns: T 39.2C, HR 110, BP 128/78, SpO2 99% RA.

Result: Pre-populated LP template with indication (meningitis workup), normal coags confirmed, no allergy concerns, specimen handling section pre-filled (tube 1: cell count/diff, tube 2: glucose/protein, tube 3: Gram stain/culture, tube 4: hold for additional studies), opening pressure documentation field, post-LP instructions (flat 1-2 hours, monitor for headache).

Troubleshooting

Pre-procedure labs are older than 24 hours

• Flag prominently: "Labs dated [date] -- [X] hours old. Consider recheck before procedure if clinically indicated."
• For INR and platelets, 24-48 hours is generally acceptable if no interval events (bleeding, transfusion, new anticoagulation).
• For hemoglobin in actively bleeding patients, recommend point-of-care testing.

Consent resource not found in FHIR

• Consent resources are not universally implemented in FHIR servers. Many systems store consent in paper or scanned documents.
• Search DocumentReference for scanned consent: fhir_search DocumentReference with patient=[id]&type=http://loinc.org|59284-0 (LOINC 59284-0 = Consent document).
• If not found, prominently flag: "INFORMED CONSENT STATUS: UNABLE TO VERIFY IN ELECTRONIC RECORD -- confirm paper consent before proceeding."

Procedure-specific CPT code not in standard list

• Use SNOMED CT coding as an alternative: system: "http://snomed.info/sct".
• Common SNOMED codes: 233573008 (central line), 52765003 (intubation), 277762005 (lumbar puncture), 86088003 (paracentesis), 91602002 (thoracentesis).
• If no standard code matches, use code.text with the procedure name as free text.

Related Skills

• soap-note-generator - For documenting the encounter containing the procedure
• progress-note-writer - For post-procedure daily documentation
• lab-result-interpreter - For interpreting pre-procedure lab values
• preoperative-lab-checklist - For verifying all required pre-procedure labs are current