An ordered record of a procedure that was performed: what happened, the consent discussion, site, technique, findings and instructions given. It is a documentation aid rather than instructions for performing a procedure.
How to fill it in
- Copy the blank template into your record system.
- Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
- Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.
Identify what was actually done and its status: completed, attempted, modified or abandoned. Distinguish the intended procedure from the performed one. Record the date and operator in the appropriate record-system fields.
Indication and consent
Record the stated reason for the procedure and the consent discussion that occurred, including the person’s decision and any material limitation documented by the clinician. “Discussed”, “consented”, “declined” and “deferred” describe different events. Do not reconstruct consent from a completed procedure.
Site and laterality
Record the anatomical site, side and other localisation established during the encounter. Use the clinician’s precise description rather than a guessed side. If a site detail is missing or disputed, preserve that uncertainty for review; the template does not resolve it.
Anaesthetic
Record what was administered, including agent, concentration, amount, route and timing when stated. Distinguish “none used” from “not recorded”. This section records administration; it never calculates or recommends a dose.
Technique and findings
Describe the sequence actually performed and the findings observed. Useful status words include “attempted”, “completed”, “modified” and “unable to complete”. Preserve measurements and procedural limitations rather than supplying an expected technique from the procedure name.
Specimen
Record whether a specimen was taken and its established type, site, label and destination. Distinguish a sample collected from one dispatched or a result returned. “No specimen taken” must be an established fact, not a default.
Complications
Record complications observed and actions actually taken. “No immediate complication observed” has a bounded meaning; it does not guarantee a later outcome. Leave an unassessed outcome explicit rather than inserting “none”.
Post-procedure instructions and follow-up
Record the instructions actually given, the recipient and any stated follow-up responsibility or timing. Identify written information or a booked appointment when provided. Do not add standard wound care, restrictions or warning symptoms that were not stated.
Common omissions
The actual procedure status, side, administered amount, specimen destination and who received instructions are easy to miss. A template must not become retrospective proof of consent or completion.
Review before saving
Compare the performed procedure with its indication, site, anaesthetic and specimen record. Check that complications and instructions reflect the documented encounter and that pending follow-up remains visibly pending. Follow local procedural documentation requirements.
Free to copy and adapt this template and guide, including for use in your practice. Sources linked above retain their own terms.
Use this guide to help write the record. It provides no clinical advice. The clinician remains responsible for checking that the record is accurate and complete. Check Medicare requirements, statutory forms and local policies separately.