Bedside Procedure Note (Pediatric Surgery)

Date/Time Performed: [Procedure start date/time]

Location: [Unit, room, bed]

Procedure Performed By: [Name, role (resident/APP/fellow/attending)]

Attending Surgeon: [Name]

Others Present: [Names and roles present (RN, respiratory therapy, child life, family)] (Omit if none)

Procedure Summary

Procedure: [Standardized procedure name]

Anatomic Site: [Location with laterality; include drain identifiers or wound description as applicable]

Indication: [Brief clinical rationale; tie to symptoms, output trends, imaging, or care plan]

Urgency: [elective / urgent / emergent]

Consent

[Consent narrative] (State who provided consent with name and relationship, whether verbal or written, and confirm discussion of risks, benefits, alternatives, and expected discomfort with questions answered. For pediatric patients, document child engagement and whether assent was obtained or attempted if developmentally appropriate. If consent not obtained under emergency exception, explicitly state why.)

Pre-Procedure Safety

[Time-out documentation] (State that a time-out was performed, who participated, and verification of patient identity, procedure, and site/laterality. Note site marking status if applicable.)

Analgesia and Sedation

(Include this section when any analgesic, anxiolytic, local anesthetic, or sedation was used. If none used, state "None" or omit section entirely.)

• Medications: [Medication name(s) with dose, route, and timing] (Include if systemic analgesics/anxiolytics/sedatives used)
• Local Anesthetic: [Drug, concentration, volume, injection site] (Include if used)
• Sedation Reference: [Reference to separate sedation record with key summary points] (Include if procedural sedation performed)
• Non-Pharmacologic Measures: [Comfort measures used (child life, caregiver presence, distraction, topical anesthetic)] (Include if used)

Procedure Details

[Skin preparation and sterile technique] (Describe antiseptic used, draping, and sterile technique.)

[Technique narrative tailored to the procedure performed] (Provide concise step-wise description sufficient for another clinician to understand what was done and guide ongoing care.)

• If drain removal: [Securing suture removal; technique of drain removal; confirmation drain removed intact; exit site appearance; dressing applied]
• If wound opening and packing: [Wound location and dimensions; method of opening; drainage character and amount; irrigation solution and volume if performed; packing material and approximate amount placed; dressing layers applied]
• If suture/staple removal: [What was removed; wound appearance; aftercare provided]

Specimens/Cultures: [Type, source, destination] (Include only if obtained)

Estimated Blood Loss: [minimal / approximate mL] (Omit if negligible and not clinically relevant)

Findings

[Clinically significant intra-procedural findings] (Briefly describe key observations, e.g., wound appearance, drainage quality, tissue condition. May integrate into Procedure Details if natural.)

Complications

[Complication statement] (Always include. State "No immediate complications" if none occurred. If a complication occurred, describe the event, management steps taken, who was notified, and any change in disposition.)

Patient Tolerance and Condition

[Tolerance and post-procedure condition] (Document how patient tolerated procedure. Note vital sign stability if analgesia or sedation used. Include pain assessment and neuro/respiratory status if relevant. Describe final site appearance after dressing application.)

Post-Procedure Plan

• [Dressing or packing change schedule and responsible party]
• [Wound care precautions]
• [Expected drainage and thresholds for concern]
• [Analgesia plan]
• [Antibiotic changes, if any]
• [Escalation criteria (signs of infection, bleeding, respiratory changes)]
• [Timing of next surgical team reassessment]
• [Parent/guardian and primary team/RN notification of aftercare plan]

Attestation

(Include this section when the procedure was performed by a trainee. Omit if attending surgeon performed independently.)

[Attestation statement] (Document who performed the procedure and the supervising attending's involvement: physically present for entire procedure, present for key portions, or immediately available. Use language consistent with institutional supervision and billing policies.)