Performed by: Authorized by: Consent: Verbal consent obtained. Risks and benefits: Risks, benefits, and alternatives were discussed Consent given by: Patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Type: abscess Location details: xxx Anesthesia: local infiltration Local anesthetic: lidocaine 1% with epinephrine Anesthetic total: 15 ml Patient sedated: no Scalpel size: 11 Incision type: single straight Complexity: simple Drainage: purulent Drainage amount: moderate Wound treatment: packed Packing material: iodaform Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Abscess Repacking by MD Performed by: Authorized by: Consent: Verbal consent obtained. Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Type: abscess Location details: xxx Wound treatment: packed with gauze/vessel loop placed Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Performed by: Authorized by: Consent: Verbal consent obtained. Written consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Procedure consent: procedure consent matches procedure scheduled Required items: required blood products, implants, devices, and special equipment available Patient identity confirmed: arm band and verbally with patient Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Preparation: Patient was prepped and draped in the usual sterile fashion. Local anesthesia used: yes Anesthesia: local infiltration Local anesthetic: lidocaine 1% without epinephrine Anesthetic total: 4 ml Patient sedated: no Location: knee Technique: medial approach Patient tolerance: Patient tolerated the procedure well with no immediate complications. Comments: X ccs removed without complication
Performed by: Authorized by: Consent: Verbal consent obtained. Written consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Procedure consent: procedure consent matches procedure scheduled Required items: required blood products, implants, devices, and special equipment available Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Sedation type: moderate (conscious) sedation Sedatives: propofol Analgesia: fentanyl Vitals: Vital signs were monitored during sedation. Pre-procedure rhythm: atrial fibrillation Patient position: patient was placed in a supine position Chest area: chest area exposed Electrodes: pads Electrodes placed: anterior-posterior Number of attempts: 1 Attempt 1 mode: synchronous Attempt 1 shock (in Joules): 150 Post-procedure rhythm: normal sinus rhythm Complications: no complications Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Performed by: Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Required items: required blood products, implants, devices, and special equipment available Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Body area: ear Localization method: visualized Removal mechanism: ear scoop, alligator forceps and balloon extraction, irrigation Complexity: complex Objects recovered: 1 Post-procedure assessment: foreign body removed Patient tolerance: Patient tolerated the procedure well with no immediate complications
External Jugular Vein Access Performed by: Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Indications: vascular access Preparation: skin prepped with 2% chlorhexidine Skin prep agent dried: skin prep agent completely dried prior to procedure Location details: right external jugular Patient position: Trendelenburg Catheter type: IV catheter Pre-procedure: landmarks identified Successful placement: yes Post-procedure: dressing applied Assessment: blood return and free fluid flow Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Performed by: Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Required items: required blood products, implants, devices, and special equipment available Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Treatment site: right anterior and right posterior Repair method: nasal balloon Post-procedure assessment: bleeding stopped Treatment complexity: simple Patient tolerance: Patient tolerated the procedure well with no immediate complications
Performed by: Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Body area: eye Local anesthetic: tetracaine drops Anesthetic total: 1 drop Patient cooperative: yes Localization method: slit lamp Removal mechanism: moist cotton swab Eye examined with fluorescein. Complexity: simple Objects recovered: 1 Post-procedure assessment: foreign body removed Patient tolerance: Patient tolerated the procedure well with no immediate complications. Comments:
Authorized by: Performed by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Location details: abdomen Procedure: using gentle pressure, new g-tube was placed with normal saline injected afterward to fill balloon port Results: KUB with contrast confirms proper placement Complication: Tolerated well without complication.
Performed by: Authorized by: Consent: Verbal consent obtained. The procedure was performed in an emergent situation. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Procedure consent: procedure consent matches procedure scheduled Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Indications: vascular access and central pressure monitoring Anesthesia: local infiltration Local anesthetic: lidocaine 2% with epinephrine Anesthetic total: 4 ml Preparation: skin prepped with 2% chlorhexidine Skin prep agent dried: skin prep agent completely dried prior to procedure Sterile barriers: all five maximum sterile barriers used - cap, mask, sterile gown, sterile gloves, and large sterile sheet Hand hygiene: hand hygiene performed prior to central venous catheter insertion Location details: right internal jugular Patient position: Trendelenburg Catheter type: triple lumen Pre-procedure: landmarks identified Ultrasound guidance: yes Number of attempts: 1 Successful placement: yes Post-procedure: line sutured and dressing applied Assessment: blood return through all parts, free fluid flow, placement verified by x-ray and no pneumothorax on x-ray Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Performed by: Authorized by: Consent: Verbal consent not obtained. The procedure was performed in an emergent situation. Required items: required blood products, implants, devices, and special equipment available Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Indications: respiratory failure and airway protection Intubation method: direct Patient status: paralyzed (RSI) Preoxygenation: BVM and nonrebreather mask Sedatives: etomidate Paralytic: succinylcoline Laryngoscope size: Mac 4 Tube size: 7.5 mm Tube type: cuffed Number of attempts: 1 Cords visualized: yes Post-procedure assessment: chest rise, BS = bilaterally none over epigastrum, +CO2 detector Breath sounds: equal and absent over the epigastrium Cuff inflated: yes ETT to lip: 22 cm Tube secured with: adhesive tape Chest x-ray interpreted by me. Chest x-ray findings: endotracheal tube in appropriate position Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Performed by: Authorized by: Consent: The procedure was performed in an emergent situation. Risks and benefits: risks, benefits and alternatives were discussed Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Indications: rapid vascular access Insertion site: right proximal tibia Site preparation: chlorhexidine Insertion device: drill device Insertion: needle was inserted through the bony cortex Number of attempts: 1 Confirmation method: stability of the needle, easy infusion of fluids and aspiration of blood/marrow Secured with: protective shield Patient tolerance: Patient tolerated the procedure well with no immediate complications
Lac Repair (with Dermabond) Performed by: Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient or guardian understanding: States understanding of the procedure being performed Patient or guardian consent: Understanding of the procedure matches consent given Patient identity confirmed: arm band and verbally with patient Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Body area: X Laceration length: X cm Foreign bodies: no foreign bodies Tendon involvement: none Nerve involvement: none Vascular damage: no Anesthesia: local infiltration Local anesthetic: none Anesthetic total: 0 ml Patient sedated: no Preparation: Patient was prepped and draped in the usual sterile fashion. Irrigation solution: saline Irrigation method: jet lavage and syringe Amount of cleaning: extensive Debridement: none Degree of undermining: none Skin closure: Dermabond Number of sutures: NA Technique: simple Approximation: close Approximation difficulty: simple Dressing: antibiotic ointment/4x4 gauze Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Lac Repair Performed by: DONALDSON, ROSS IRELAND Authorized by: DONALDSON, ROSS IRELAND Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient or guardian Patient or guardian understanding: patient or guardian states understanding of the procedure being performed Patient or guardian consent: the patient or guardian's understanding of the procedure matches consent given Patient identity confirmed: arm band and verbally with patient Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Body area: X Laceration length: X cm Foreign bodies: no foreign bodies Tendon involvement: none Nerve involvement: none Vascular damage: no Anesthesia: local infiltration Local anesthetic: lidocaine with epinephrine Anesthetic total: 4 ml Patient sedated: no Preparation: Patient was prepped and draped in the usual sterile fashion. Irrigation solution: saline Irrigation method: jet lavage and syringe Amount of cleaning: extensive Debridement: none Degree of undermining: none Skin closure: 6-0 nylon Number of sutures: X Technique: interupted Approximation: close Approximation difficulty: simple Dressing: antibiotic ointment/4x4 gauze Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Lac Repair with Staples Performed by: Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient or guardian understanding: States understanding of the procedure being performed Patient or guardian consent: Understanding of the procedure matches consent given Patient identity confirmed: arm band and verbally with patient Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Body area: scalp Laceration length: X cm Foreign bodies: no foreign bodies Tendon involvement: none Nerve involvement: none Vascular damage: no Anesthesia: local infiltration Local anesthetic: lidocaine with epinephrine Anesthetic total: 4 ml Patient sedated: no Preparation: Patient was prepped and draped in the usual sterile fashion. Irrigation solution: saline Irrigation method: jet lavage and syringe Amount of cleaning: extensive Debridement: none Degree of undermining: none Skin closure: Staples Number of staples: X Technique: simple Approximation: close Approximation difficulty: simple Dressing: antibiotic ointment/4x4 gauze Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Performed by: Authorized by: Consent: Verbal consent obtained. Written consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Procedure consent: procedure consent matches procedure scheduled Relevant documents: relevant documents present and verified Test results: test results available and properly labeled Site marked: the operative site was marked Imaging studies: imaging studies available Patient identity confirmed: arm band and verbally with patient Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Anesthesia: local infiltration Local anesthetic: lidocaine 1% without epinephrine Anesthetic total: 4 ml Patient sedated: no Preparation: Patient was prepped and draped in the usual sterile fashion. Lumbar space: L4-L5 interspace Patient's position: lateral decubitus Needle gauge: 22 Number of attempts: 1, atraumatic Opening pressure: XX cm H2O Fluid appearance: clear Tubes of fluid: 4 Total volume: 4 ml Post-procedure: site cleaned and pressure dressing applied Patient tolerance: Patient tolerated the procedure well with no immediate complications. Comments: Nontraumatic
Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Location details: XXX finger Injection: using standard, sterile technique 4 cc of lidocaine without epinepherine injected Complication: Tolerated well without complication.
Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: Guardian Patient understanding: Guardian states understanding of the procedure being performed Patient consent: Guardian's understanding of the procedure matches consent given Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Location details: arm Reduction Procedure: gentle flexion/supination followed by extension/pronation Results: After procedure, the patient was able to move the arm fully without pain. No TTP. Issue fully resolved and patient back to normal. Complication: Tolerated well without complication. DNVI.
Performed by: Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Required items: required blood products, implants, devices, and special equipment available Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Body area: ear Localization method: visualized Removal mechanism: ear scoop Placement: Ear wick Objects recovered: NA Post-procedure assessment: copious discharge removed Patient tolerance: Patient tolerated the procedure well with no immediate complications
Performed by: Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and guardian Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Wound treatment: packing changed Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Performed by: Authorized by: Consent: Verbal consent obtained. Written consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Procedure consent: procedure consent matches procedure scheduled Required items: required blood products, implants, devices, and special equipment available Patient identity confirmed: arm band and verbally with patient Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Preparation: Patient was prepped and draped in the usual sterile fashion. Local anesthesia used: yes Anesthesia: local infiltration Local anesthetic: lidocaine 1% without epinephrine Anesthetic total: 4 ml Patient sedated: no Patient tolerance: Patient tolerated the procedure well with no immediate complications. Comments: X liters removed without complication
Authorized by: Performed by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Location details: penis Injection: using standard, sterile technique 8 cc of lidocaine without epinepherine injected circumferentially Complication: Tolerated well without complication.
Authorized by: Performed by: Consent: Written consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Location details: penis Reduction Procedure: Slow direct pressure first applied; followed by reduction using direct pressure Results: After procedure, fully reduced. Complication: Tolerated well without complication.
Incision/Drainage of Paronychia Performed by: Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Procedure consent: procedure consent matches procedure scheduled Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Type: abscess Body area: upper extremity Location details: XX finger Anesthesia: nerve block Local anesthetic: lidocaine 1% without epinephrine Anesthetic total: 4 ml Incision type: single straight Complexity: simple Drainage: purulent Drainage amount: mod Wound treatment: drain placed Packing material: 1/4 in gauze Patient tolerance: Patient tolerated the procedure well with no immediate complications. Comments: With iris sissors, dissected along top of nail.
Incision/Drainage of Peritonsillar Abscess Performed by: Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and guardian Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Type: peritonsilar abscess Location details: right Anesthesia: local infiltration and spray Local anesthetic: lidocaine 1% with epinephrine and benzocaine spray Anesthetic total: 2 ml Patient sedated: no Incision type: straight puncture to 1.5 cm with spinal needle covered by plastic cover Attempts: 3 Drainage: purulent drainage Drainage amount: 5cc Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Orthopedic Reduction (Digit) Authorized by: Performed by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Location details: X Reduction Procedure: gentle hyperextension and axial pull Results: After procedure, digit was fully mobile Complication: Tolerated well without complication.
Authorized by: Performed by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Location details: ? Reduction Procedure: axial pull and closed manipulation Results: Post reduction alignement improved Complication: Tolerated well without complication.
Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Location details: XX hernia Reduction Procedure: Direct pressure, constant Results: After procedure, fully reduced. No TTP. Complication: Tolerated well without complication.
Authorized by: Performed by: Consent: Written consent obtained (see nursing note) Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: states understanding of the procedure being performed Patient consent: understanding of the procedure matches consent given Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Medication IV: XXX Complication: Tolerated well without complication. No hypoxic episodes. Time: Total intra-service time with patient was 17 minutes.
Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Location details: XX Post-procedure: The splinted body part was neurovascularly unchanged following the procedure. Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Incision/Drainage of Subungual Hematoma Performed by: Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: states understanding of the procedure being performed Patient consent: understanding of the procedure matches consent given Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Type: abscess Location details: xxx Anesthesia: NA Patient sedated: no Incision type: single with electric cautery Complexity: simple Drainage: blood Drainage amount: moderate Wound treatment: dressed Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Performed by: Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Body area: XXX Wound Appearance: clean Post-removal: Steri-Strips applied and antibiotic ointment applied Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and/or guardian Patient understanding: patient/guardian states understanding of the procedure being performed Patient consent: the patient/guardian's understanding of the procedure matches consent given Patient identity confirmed: verbally with patient and arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Location details: xxx Injection: using standard, sterile technique 4 cc of lidocaine without epinepherine injected to cover all 4 nerves (2 injections) Complication: Tolerated well without complication.
Performed by: Authorized by: Consent: Verbal consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient and guardian Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Type: ingrown toenail Location details: xxx Procedure: Below toenail blunt dissected with kelly to base. Then, peripheral nail clamped and torqued until linear break to base of nail including growth area, and removed. Complication: None Wound treatment: 4x4 Patient tolerance: Patient tolerated the procedure well with no immediate complications