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Medical Transcription: Procedure Notes

Procedures that you might see in medical transcription range from placement of a feeding tube, to cardioversion to correct a heart rhythm, to a colonoscopy — pretty much anything that doesn’t require a full-blown operating room (OR) and surgical team.

Many procedures are diagnostic in nature, such as electroencephalographies (EEGs), sleep studies, and cardiac stress tests. The reports may detail a procedure done in a physician’s office, at a hospital bedside, or in a specialty clinic.

Some simply name the procedure and then give a brief summary of the process and pertinent findings; others are precisely formatted and include procedure-specific subheadings. The first thing all of them do is identify the procedure, like this:

PROCEDURE PERFORMED
Colonoscopy.

Indications for procedure

The body of a procedure note begins by explaining why the procedure is being performed:

INDICATIONS FOR PROCEDURE
This is a 72-year-old female with a history of rectal bleeding.

Alternative section names include Preoperative Diagnosis and Reason for Procedure, or sometimes, when more detail is included, History.

Medications

When a list of the patient’s current medication is dictated in a procedure note, the medications should be numbered and listed vertically.

CURRENT MEDICATIONS
1. Ambien.
2. Plavix.

Unlike a patient’s full medication list, anesthesia or procedure-related medications don’t need to be numbered or formatted vertically unless the facility specifies it.

PREMEDICATIONS
Versed 5 mg, Demerol 75 mg IV.

Procedure in detail

The body of the report provides a narrative description of the procedure. This section is also commonly given the title Technique.

PROCEDURE IN DETAIL
The Olympus video colonoscope was introduced into the rectum and advanced under direct visualization to the cecum and into the terminal ileum. No abnormalities were seen of the terminal ileum, the ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid, and rectum. Retroflexion exam in the rectum revealed no abnormality. The colonoscope was withdrawn. The patient tolerated the procedure well.

If a procedure includes measurements as part of the procedure process, they often will be interwoven into the narrative.

Findings and recommendations

When not already stated at the beginning of the report as postoperative diagnoses or bundled into the procedure description, the results of a diagnostic study appear in a section titled Findings, Conclusion, or Impression, similar to this:

FINDINGS
1. Small internal hemorrhoids.
2. Otherwise unremarkable colonoscopy.
RECOMMENDATIONS
High-fiber diet. Repeat colonoscopy in 5 years.
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