Dictate Like A Pro Procedures
PROCEDURE: Endotracheal Intubation
PHYSICIAN: NAME (RESIDENT) NAME (ATTENDING)
DATE:
INDICATIONS FOR PROCEDURE: Respiratory failure, Sepsis, AMS, Pulmonary Edema
CONSENT: The procedure risks and benefits were explained to the patient including those of bleeding, infection, injury, anesthesia, allergic reaction and ventilator
dependence. Alternatives were explained to the patient who voiced an understanding of the information. The questions were sought and answered. The patient agreed to the
procedure of the lumbar puncture. A permit was signed and placed on the chart. OR The consent for the intubation was implied due to the respiratory failure of the patient
PROCEDURE IN DETAIL: The patient was placed on cardiac and oxygenation monitors and preoxygenated with NRB mask to 100% oxygen saturation. All equipment
was checked including the balloon cuff. Rapid sequence intubation was then initiated by giving 20mg of etomidate and 120 mg of succinylcholine resulting in good sedation
and muscle relaxation. The patient was then laid in the supine position and a Mac 3 blade was used to visualize the vocal cords. A 7 French tube was then easily passed
though the vocal cords on first attempt with good visualization of the vocal cords and no resistance. The tube was placed at 22 cm at the lip with good capnograhy color
change, bilateral breath sounds heard and good chest rise and fall. The pt was easily bagged without restrictions. The patient was then placed on a Diproivan drip tirtated to
the Ramsey 4 criteria for sedation. Vent settings were set: AC, FIO2 of 100%, peep of 5, title volume of 600 and a rate of 12. Stat CXR was taken showing good placement
of the tube 4cm above the carina. ABG was ordered for 30 min results to be called to patients physician. The patient was then left in the care of Dr.-----). The patient was
sedated comfortably with good capillary refill and 100% O2. There were no complications for this procedure and there was minimal blood loss.
PROCEDURE: Lumbar Puncture
PHYSICIAN: NAME (RESIDENT); NAME (ATTENDING) DATE:
INDICATIONS: Headache, AMS
CONSENT: The procedure risks and benefits were explained to the patient including those of bleeding, infection, injury, anesthesia and allergic reaction and Headache.
Alternatives were explained to the patient who voiced an understanding of the information. The questions were sought and answered. The patient agreed to the procedure of
the lumbar puncture. A permit was signed and placed on the chart.
PROCEDUREN IN DETAIL: The patient was placed in the right lateral position and the L4-L5 spine was prepped and draped in a sterile fashion. Local anesthetic, 5 ml of
1% lidocaine without epinephrine, was injected with good anesthetic results. The area was then palpated for the L4-L5 inter spinous space and a 20 (22) gauge lumbar
needle was introduce. Good CSF return was found on the first attempted. This was a somewhat traumatic tap, with multiple attempts secondary to (body habitus, scoliosis,
osteophytes). The opening pressure was 20. The fluid was clear. Four vials were collected and sent for gram stain, culture, cell count, differential, glucose and protein. The
stilet was replace and the needle removed intact. There were no complications associated with this procedure. There was a minimal amount of blood loss. The patient was
alert, oriented, resting and breathing comfortably. All extremities were neurovasc intact. The patient was given post lumbar puncture instructions and remained in the supine
for one hour after the procedure.
PROCEDURE: Central Line
INDICATIONS: Hypotension, need for multiple drugs and fluids
CONSENT: same as above
DESCRIPTION OF THE PROCEDURE: The patient was placed on cardiac and oxygenation monitors, in the trendelenburg position. The area of the right
sternocleidomastioid and neck were prepped with chlorhexidine and draped in a sterile fashion. I was dressed in full sterile attire. The patent was sedated using propofol.
Local anesthetic of 5ml of 1% lidocaine was used. The vein was then visualized using steril ultrasonography technique and cannulate on first attempt. Dark non-pulsatile
blood was easily withdrawn. A wire was passed through the vein with out resistance the central line was then placed over the wire and the wire removed intact. The central
line was secured in place at 16cm with 2 x 2.0 silk sutures. All ports withdrew and flushed without resistance, no extravasations were seen. The skin was cleaned and
Bioderm and Tegaderm dressings placed. A stat chest x-ray showed good line placement and no ptx There were no complications associated with this procedure. There
was __ml of blood lost. The patient was left intubated sedated and vascularly intact with good cap refill and motion in all 4ext at 100% oxygenation saturation. .
PROCEDURE: Paracentesis
INDICATION: Therapeutic vs R/o SBP
CONSENT: same as above but include Bleeding, infection, damage to organs and bowel
DESCRIPTION OF THE PROCEDURE: The pt had basic labs drawn including coags all were with in normal limits. The patient was placed in the supine position on
cardiac and o2 monitors. The area of most ascitic fluid was then visualized with ultrasonography and marked. The abdomen was then prepped and draped in a sterile
fashion. Local anesthetic of 5ml of 1% lidocaine was used. An 11 blade was used to make a small skin incision. The safteysentisis needle and catheter was then used to z
track into the peritoneal cavity. Once ascitic fluid was easily returned the catheter was advanced into the peritoneal cavity and the needle removed. Three 5 ml bottles of
(turbid/amber/serosang/clear/yellow) fluid were collected and sent to the lab for analysis. The tubing was then connected and 6 liters of fluid was drawn off. The catheter
was then removed intact. The puncture was then bandaged. At the end of the procedure the patient was resting comfortably neurovasc intact. . ----of Albumin was given to
replete losses. There were no complications. There was minimal blood lost. He was observed on monitors for 1 hour and had no complications
PROCEDURE: Conscious Sedation
INDICATION: Reduction or what ever
CONSENT: Respiratory depression, aspiration, allergic reaction
DESCRIPTION OF THE PROCEDURE: Placed on monitors CV/O2, and 2l nc O2 applied, the patient was placed in the ___ position. The ortho tech, nurse, RT at bedside.
ASA Status assigned: I – normal and healthy, II – mild to mod disease (ie controlled DM/HTN), III-severe disease but not incapacitating, IV-Severe diseases that limits
activity and is a life threat, V- Not expected to survive more that 24 hours . Presedation the pt was in NAN and VS were normal and stable and the nurse monitored the VS
throughout the procedure, please seen nursing notes for details. The patients last meal was___. Sedation medication was administered via IV ___mg of ____ with good
anesthetic sedative results. The procedure was preformed……... Vital signs remained stable during and after the procedure. Te pt was observed for 1 hour post procedure
with out complications and was A and O x 4, moving all extremities with 5/5 strength and was able to ambulate and take po fluids without difficulty.
PROCEDURE: Fracture/Dislocation Reduction
INDICATION: location and description of fracture
CONSENT: neuro vasc injury
DESCRIPTION OF THE PROCEDURE: Pt was place on CV and oxygenation monitors. Neurovascular exam showed ____ with ___cap refill in the affected extremity.
Conscious sedation/ hematoma block was preformed. The fracture/dislocation was then reduced with ____traction and distraction. The injury was then splinted. The distal
extremity remained neurovascuarly intact with 5/5 strength and 2+ distal pulses. Post reduction xray showed satisfactory/improved/inadequate alignment. There were no
complications, no blood was lost. The patient will follow up with ____, and has been given fracture/dislocation, splint and crutch/sling instructions. The patient tolerated the
procedure well.
PROCEDURE: Laceration
INDICATIONS: Simple(one layer), Intermediate (2 layer or contaminated), Complex (2 layer plus debridement/undermining); length , depth, location.
CONSENT:
DESCRIPTION OF THE PROCEDURE: Skin was prepped and draped, 5ml of 1% lido with epi was administered with good anesthetic result. The wound was explored for
FB or deep tendon and neurovascular injury and copiously irrigated under pressure. No injury was found (the laceration was found to have extensive injury/debris that was
removed/repaired). The laceration was closed using 2 deep mattresses of 2.0 vicyl, followed by 10 interrupted 3.0 nylon sutures with good approximation and hemostasis.
distal extremity remained neurovascuarly intact with 5/5 strength and 2+ distal pulses. Post reduction xray showed satisfactory/improved/inadequate alignment. There were
no complications, no blood was lost. The patient will return for a wound check in 2 days and will have the stitches removed in __ days. The pt has been given suture wound
care and suture instructions.
“Critical care time ____exclusive of procedures”
General ED Note
CC: “I have……..”
#8045
HPI:
71(med) or 73(trauma)=Admit
70(med) or 72(trauma)=D/C
7=stop
2=start
3=rewind
4=end
8=end
This is a __ y/o f/m presenting with _____for ____days/week.
The pain/symptom started at __in the afternoon/morning while the patient was____. (speed, mech, seat belt/airbag, helmet, LOC, ambulatory, fatalities)
It is X/10, sharp/crampy/pressure pain located ____ with (out) radiation (to the___).
The (symptom) is intermittent/continuous and increases with _____. Decreases with ____. Associated with (perinate positives for CC )
The patient has (not) had similar symptoms/pain in the past (and has had___ treatment/workup/hospitalization/diagnosis).
The patient denies (perinate negatives)
The patient also mentions (other pos ros) that are not associated with this complaint.
ROS: A ten systems were reviewed and were negative except as stated in the HPI (is limited, obtained by ems)
General: Changes: Weight, Mood, Energy Level, Fever
Head: HA, syncope, dizzy/lightheaded, pain, swelling (malocclusion, trauma) Ear: D/c, tinnitus, fullness, change in hearing (Hemotympanum)
Eye: Change in vision (spots/loss/blurry/double), photophobia, pain, discharge N: nasal obstruction, changes in smell, epistaxis
T: Cough, ST, dysphagia, odynophagia, hoarseness, pain, TMJ, Bad breath, cavities, Gums bleeding
Respiratory:
Cough (productive/hemoptysis/color/duration), Dyspnea/SOB, DOE, PND, Wheezing, asthma, Pneumonia, TB
CV: CP, Syncope, PND, DOE, N/V, diaphoresis, palpitations, edema, claudication, DVT, orthopnea, HTN, CAD, Stents, CABG, murmurs,
GI: Abd Pain (location), N/V, diarrhea, distention, GRED, appetite, dysphagia, last BM (B/B/M), rectal pain, hemorrhoids
GU: Urgency, frequency, dysuria, hematuria, discharge, incontinence, difficulty starting/stopping stream, nocturia, enuresis
Reproductive: Dyspareunia, genital lesions, discharge odor, itching, (scrotal masses, or testicular pain), (LMP – reg)
Musculoskeletal: Pain, cramps, weakness, numbness, edema, ROM, deformities, trauma, erythema
Neurologic: Syncope, dizziness/vertigo, LOC, weakness/paralysis/numbness/tingling, dysphagia, dysphasia, ataxia, vertigo, tremors.
Endocrine: Heat/Cold intolerance, dry skin, change in voice, weight, hair, polydypsia, polyuria, goiter, irregular menses.
Psychological: Depression, loss of motivation, anxiety, mood/memory changes, changes in sleep/diet, SI, HI, AH, VH
Allergies: NKDA
Sx Hx:
______ (Reaction)
Medication:
Past Medical History: CAD, Vascular Dz, CA, PE/DVT, Recent hosp, Recent infections
GYN Hx: LMP (irreg/reg) GPAL with ___new sexual partners does (not) use condoms. Has (not) had ___ STDs
Family History: CAD, HTN, DM, CA, Vascular/Bleeding disorders, brain tumors/aneurysms, stones
Social History: The patient works as a ____ and lives alone/at shelter/on streets; Smoking/Drinking/Drugs (IVDU)
Physical Exam:
GENERAL:
Vitals: TPR BP Pulse Ox (normal)
WNWD (obese), NAD (Some distress/Extreme distress) A&Ox3, GCS 15 ….add what they are doing (texting, eating etc)
Head:
NC/AT, Cranial and Facial bones are NTTP (sinuses and temple), sensation intact. (bruises, laceration)
Eyes:
PERRLA, EOMI s pain; No injection, icterus, disconjugation, nystagmus, afferent defect, proptosis, corneal clouding, hypopyon, hyphema
Ears:

Visual fields grossly intact: Acuity, Fluorescin stain s ulceration, dendrite, abrasion, Seidel sign. Tonopen pressures

Fundoscopic: Optic disc is clear yellow/pink with defined boarders. Lid; Laceration ( tarsal plate/lacrimal involvement),swelling
Canals patent bilaterally s discharge or inflammation; TM’s demonstrate normal cone of light s erythema or hemotympanum.
Nose/O/P: Nose and O/P have a pink moist mucosa without erythema, exudate or lesions.
No polyps, masses, discharge, septal hematoma
Uvula is midline, Gums & teeth in good repair (malocclusion)
NECK : NT, supple with trachea midline: No masses, LAD, palpable thyroid, JVD, bruits, ejection murmur, crepitus, pain with ROM, trismus
THORAX:
Lungs: CTA B c full excursion. No Wheezing, rhonchi, rales, rubs, retractions, stridor, crackles (flail lung, PTX)
Heart: RRR No Murmurs/Rubs/Gallops/Thrills/Clicking murmurs . Chest is NTTP
ABDOMEN: Abd: Flat (striae/scars/distention), BS+,, NT/ND; No rebound, guarding, masses, HSM, ascites, CVA, McBurney, Murphy’s, pulsitile
GU: Ext genitalia s lesions. Spec/BM exam showed (d/c, bleeding, OS, CMT, Adnexal tenderness). Testical (vertical lye s masses, TP, + cremaster)
Rectal: Sphincter is normal in appearance and tone, no masses, fissures, hemorrhoids. Guaiac ___
MUSCULOSKELETAL:

FROM with good pulses and capillary refill:
DTR: 4+ Strength: 5/5 s deformity/erythema NO CCE, Homans
C/T/L Spine demonstrate normal curvature; FROM symmetrical & full, no crepitus, Spinous process NTTP
SKIN: Warm and dry (rash, lacerations, lesions, petechia, ecchymosis/bruising, deformities, moles, pressure sore,)
NEUROLOGIC: GCS 15, A&0X3, Cranial nerves II –XII Grossly intact, No cerebellar signs (Finger to nose and Heal to shin done s diff); no dysmetria, dysarthria,
Normal equal and symmetric DTR, Strength, sensation. No visual or hearing deficits.

LE and UE Strength and sensation and strength are symmetrical 5/5, DTR 2+ in all 4 ext; Gate and Balance non disrupted (No ataxia, foot drop, shuffling gate)
Romberg sign; No Babinski nystagmus, dolls eyes, extension/flexion posturing GCS: E-4 , V–5 , M-6
Clinical Studies:

EKG: RRR @ ___ s ST change, NL intervals, no path Q-waves, no progressive changes when compared to old ekg (date/time).

LABS reviewed by myself are is normal except which is high/low.

IMMAGING as read by the radiologist and reviewed by myself shows.
ED Course/Medical Decision Making:
This is a _____y/o female/male who presents to the emergency department with_cc. The clinical evaluation and the results of here studies show___. Throughout her
time in the ed her vital signs were monitored and remained stable and normal (abnormal/ decompensated).
She was given:
Medications (pain/treatment) reassessment
IVF to stabilize  reassessment
Procedures While in the ED the patient has the following procedures. (Dictate consent/procedure note)
Family discussion, Pt discussion, fu discussion, return precautions.
Clinical Impression: (improved/resoved/worsened)
Consults:
Prescriptions: (list)
Followup The patient is to follow up at ___Clinic/Doctor in ____days.
Patient Instructions’
Disposition: The pt is discharged home or admitted (to (ICU, IMC, Med Teli) I have spoken with Dr. _____ who agrees to assume care. I wrote admission holding orders.
The patient voices understanding and agrees with of the above clinical impression and admission/discharge plan and follow up instructions.
 End of Dictation Thank you 