Procedure Log, Procedure Notes and Tray Setups


Procedure Notes and Tray Setups

Click on a procedure to see tray list and procedure note.

  1. Incision and Drainage (I & D)

    Procedure Note:
    Procedure Name: Incision and Drainage of Abscess
    Indication: Pain, risk of further infection
    Location: ***
    Pre-Procedure Diagnosis: Abscess
    Post-Procedure Diagnosis: Abscess, drained
    Informed consent was obtained before procedure started.
    Description:
    Area prepped and draped in usual sterile fashion. Local anesthesia achieved using Lidocaine 1% ***without epinephrine, ***cc. Using a No. 11 blade, a ***cm incision was made and ***cc of purulent material drained from wound. Wound was copiously irrigated and ***packing placed. EBL ***cc. A sterile bandage was applied. Patient tolerated procedure well. Return to care ***.
    Tray List:
    1. Chux (2)
    2. Betadine/Povidone Iodine (1 bottle or 3 swab-sticks)
    3. Lidocaine 1% without epinephrine (1 bottle)
    4. Alcohol prep pads
    5. Syringe, 5cc (1)
    6. Syringe, 20cc (1)
    7. Needle, 18 gauge, 1-0.5 inch length (1)
    8. Needle, 27 gauge, >1.25 inch length (1)
    9. Needle, 30 gauge, 0.5 inch length (1)
    10. No. 11 Blade (1)
    11. Swab, for microbiology/culture (1)
    12. Swab, sterile (2)
    13. Gauze, 4x4, sterile (5)
    14. Gauze, 2x2, sterile (5)
    15. Gauze, 4x4, non-sterile (1 pack)
    16. Gauze, 2x2, non-sterile (1 pack)
    17. Normal Saline or Sterile Water (1 Liter)
    18. Cup, sterile urine sample (1)
    19. Gauze, ribbon/packing, 1/4 inch width (1 bottle)
    20. Tape, paper, 1 inch width
  2. Re-Pack wound

    Procedure Note:
    Procedure Name: Re-Pack wound
    Indication: Pain, risk of further infection
    Location: ***
    Pre-Procedure Diagnosis: Abscess s/p I&D
    Post-Procedure Diagnosis: Abscess s/p I&D
    Informed consent was obtained before procedure started.
    Description:
    ***packing replaced. EBL ***cc. A sterile bandage was applied. Patient tolerated procedure well. Return to care ***.
    Tray List:
    1. Chux (1)
    2. Swab, sterile (2)
    3. Gauze, 4x4, sterile (5)
    4. Gauze, ribbon/packing, 1/4 inch width (1 bottle)
    5. Scissor
    6. Forceps
    7. Tape, paper, 1 inch width
  3. Laceration

    Procedure Note:
    Procedure Name: Laceration Repair
    Indication: Reduce risk of infection
    Location: ***
    Pre-Procedure Diagnosis: Laceration
    Post-Procedure Diagnosis: Laceration, repaired
    Informed consent was obtained before procedure started.
    Description:
    Area prepped and draped in usual sterile fashion. Local anesthesia achieved using Lidocaine 1% ***without epinephrine, ***cc. Wound was copiously irrigated. *** 5-0 Nylon interrupted sutures were placed. EBL ***cc. A sterile bandage was applied. Patient tolerated procedure well. Return to care *** for suture removal.
    Tray List:
    1. Chux (2)
    2. Betadine/Povidone Iodine (1 bottle or 3 swab-sticks)
    3. Lidocaine 1% without epinephrine (1 bottle)
    4. Alcohol prep pads
    5. Syringe, 5cc (1)
    6. Syringe, 20cc (1)
    7. Needle, 18 gauge, 1-0.5 inch length (1)
    8. Needle, 27 gauge, >1.25 inch length (1)
    9. Needle, 30 gauge, 0.5 inch length (1)
    10. Swab, sterile (2)
    11. Gauze, 4x4, sterile (5)
    12. Gauze, 2x2, sterile (5)
    13. Normal Saline or Sterile Water (1 Liter)
    14. Cup, sterile urine sample (1)
    15. Needle driver/holder (1)
    16. Pickups with teeth (1)
    17. Hemostat, small (1)
    18. Scissors for suturing, small sterile (1)
    19. Suture, nylon 5-0 (2 packs)
    20. Tape, paper, 1 inch width
  4. Excision

    Procedure Note:
    Procedure Name: Excision
    Indication: Pain, risk of infection
    Location: ***
    Pre-Procedure Diagnosis: ***
    Post-Procedure Diagnosis: ***, removed
    Informed consent was obtained before procedure started.
    Description:
    Area prepped and draped in usual sterile fashion. Local anesthesia achieved using Lidocaine 1% ***without epinephrine, ***cc. Using a No. 15 blade, a ***cm incision was made. Wound was copiously irrigated. *** 5-0 Nylon interrupted sutures were placed. EBL ***cc. A sterile bandage was applied. Patient tolerated procedure well. Return to care ***.
    Tray List:
    1. Chux (2)
    2. Betadine/Povidone Iodine (1 bottle or 3 swab-sticks)
    3. Lidocaine 1% without epinephrine (1 bottle)
    4. Alcohol prep pads
    5. Syringe, 5cc (1)
    6. Syringe, 20cc (1)
    7. Needle, 18 gauge, 1-0.5 inch length (1)
    8. Needle, 27 gauge, >1.25 inch length (1)
    9. Needle, 30 gauge, 0.5 inch length (1)
    10. No. 15 Blade (1)
    11. Swab, sterile (2)
    12. Gauze, 4x4, sterile (5)
    13. Gauze, 2x2, sterile (5)
    14. Normal Saline or Sterile Water (1 Liter)
    15. Cup, sterile urine sample (1)
    16. Needle driver/holder (1)
    17. Pickups with teeth (1)
    18. Hemostat, small (1)
    19. Scissors for suturing, small sterile (1)
    20. Suture, nylon 5-0 (2 packs)
    21. Tape, paper, 1 inch width
  5. Joint Injection

    Procedure Note:
    Procedure Name: Joint Injection
    Indication: Pain
    Location: ***
    Pre-Procedure Diagnosis: ***Arthritis
    Post-Procedure Diagnosis: Same
    Informed consent was obtained before procedure started.
    Description:
    Area prepped in usual sterile fashion. Local anesthesia achieved using Gebauer's cold spray. Lidocaine 1% without epinephrine 2cc and Kenalog 40mg in 1mL was injected into joint using *** approach. EBL ***cc. A sterile bandage was applied. Patient tolerated procedure well. Return to care ***.
    Tray List:
    1. Betadine/Povidone Iodine (1 bottle or 3 swab-sticks)
    2. Lidocaine 1% without epinephrine (1 bottle)
    3. Kenalog or Triamcinolone Acetonide 40mg/mL (1 bottle)
    4. Alcohol prep pads
    5. Syringe, 5cc (1)
    6. Needle, 18 gauge, 1-0.5 inch length (1)
    7. Needle, 23 gauge, >1.25 inch length (1)
    8. Gauze, 2x2, non-sterile (5)
    9. Gebauer's cold spray (1 bottle)
    10. Band-Aid (1)
  6. Ingrown Toenail Removal

    Procedure Note:
    Procedure Name: Toenail Removal
    Indication: Pain, infection
    Location: ***great toe
    Pre-Procedure Diagnosis: Ingrown Toenail
    Post-Procedure Diagnosis: Same, removed
    Informed consent was obtained before procedure started.
    Description:
    Area prepped and draped in usual sterile fashion. Local anesthesia achieved using Lidocaine 1% ***without epinephrine, ***cc in a digital block. Using the ***toenail clippers, the toenail was cut to its emergence from the matrix. Then using the ***spatula the toenail was undermined to the ***margin. Then using the ***toenail grabber the toenail was removed. Wound was copiously irrigated and ***packing placed. EBL ***cc. A sterile bandage was applied. Patient tolerated procedure well. Return to care ***.
    Tray List:
    1. Chux (2)
    2. Betadine/Povidone Iodine (1 bottle or 3 swab-sticks)
    3. Lidocaine 1% without epinephrine (1 bottle)
    4. Alcohol prep pads
    5. Syringe, 5cc (1)
    6. Needle, 18 gauge, 1-0.5 inch length (1)
    7. Needle, 27 gauge, 1.25 inch length (1)
    8. Gauze, 2x2, non-sterile (5)
    9. Gauze, 2" roll (1)
    10. Hemostat or Toenail grabbers (sterile)
    11. Scissors or Toenail clippers (sterile)
    12. Spatula or small Blunt Probe (sterile)
    13. Normal Saline or Sterile Water (1 Liter)
    14. Cup, sterile urine sample (1)