Pre-procedure note
Formal Definition
A documentation entry created before an invasive procedure (often required for bedside procedures, minor operations, interventional radiology procedures, and some ICU procedures) that establishes the indication, informed consent, relevant pre-procedure findings, pertinent imaging/labs reviewed, anticipated benefits and risks, planned approach, and that the appropriate timeout will be performed; functions as both a cognitive checklist for the operator and a medico-legal record that the procedure was appropriately planned.
How It's Used on the Ward
"Pre-procedure note" or "pre-procedure H&P" — the deliberate documentation entry made by the operator (resident, NP, or attending) before doing an invasive bedside procedure like central line placement, thoracentesis, paracentesis, lumbar puncture, or arterial line; required for Joint Commission and many institutional policies; ensures that thinking was done beyond just showing up to do the procedure.
Example
""PRE-PROCEDURE NOTE Procedure: Thoracentesis, right Indication: 58-year-old man with new right pleural effusion, dyspnea, possible malignant effusion in setting of stage IV NSCLC Consent: Risks including pneumothorax, hemothorax, infection, re-expansion pulmonary edema, hepatic/renal injury discussed in detail; patient verbalized understanding and consented Pre-procedure imaging: Chest CT 2 days ago showing right pleural effusion 2.5cm layering, no loculation Coags: Platelets 218, INR 1.0 — no correction needed Plan: Ultrasound-guided thoracentesis at bedside, right lateral approach, send fluid for cell count, LDH, protein, glucose, pH, gram stain/culture, cytology Operator: Dr. Smith""
Clinical Context
Components: (1) Indication — clear statement of what problem the procedure addresses. (2) Informed consent — risks/benefits/alternatives discussed, patient understanding confirmed, consent signed. (3) Pre-procedure data — relevant labs (coags for procedures with bleeding risk, k+. creatinine for contrast, platelets), imaging reviewed. (4) Pertinent findings — relevant physical exam, prior imaging, prior procedures attempted/failed. (5) Plan — specific procedural approach, anesthesia planned, equipment, post-procedure monitoring. (6) Operator — attending if solo, attending + assistant names if teaching. Joint Commission requires pre-procedure verification (right patient, right procedure, right site) immediately before — the "time-out" — which is separate from the pre-procedure note (which establishes thinking). For minor bedside procedures, often combined with the brief procedural note documenting what was done, post-procedure findings, complications.