Endovenous Ablation/Phlebectomy Procedure Note

Date/Time: [Procedure date]; [Start and end times if tracked]

Location: [Facility type]; [Procedure room]

Operators: [Primary clinician]; [Assistant(s) if applicable]; [Ultrasound technologist if applicable]

Patient: [Name]; [DOB/MRN per system policy]

(Laterality must appear with every anatomic structure throughout the note. Omit subsections that do not apply rather than documenting as "not performed." Do not infer or fabricate required elements; prompt for missing required items.)

Pre-Procedure

[Indication and diagnosis] (Briefly state the primary indication such as symptomatic varicose veins or chronic venous disease; explicitly list treated symptoms; state the working diagnosis with explicit laterality; identify planned target vein(s) and segment(s) for ablation and any tributaries planned for phlebectomy, all with laterality.)

[Pre-procedure duplex summary] (Name target vein(s) with laterality; confirm deep venous system patency; explicitly state pre-procedure DVT status; reference the formal duplex report if available; if conservative management documentation is relevant, reference the prior clinic note rather than re-documenting.)

Allergies: [Relevant allergies, particularly local anesthetics, adhesives, antiseptics, latex]

Anticoagulation status: [Current anticoagulant/antiplatelet medications and peri-procedural plan if managed by procedural team]

Consent: [Attestation that informed consent obtained for specified procedures with laterality, including risks appropriate to planned modality]

Time-out: [Attestation that universal protocol time-out completed confirming correct patient, procedure, and site/laterality]

Anesthesia plan: [Local anesthetic agent and concentration]; [Tumescent anesthesia planned: yes / no]; [Sedation plan: none / minimal anxiolysis / moderate sedation / deep sedation / general anesthesia] (If sedation used, reference where sedation documentation is recorded.)

Intra-Procedure

Procedures performed:

• Endovenous ablation: [laterality] [vein name] ([segment]), modality: [RFA / EVLA / mechanochemical / adhesive]
• Ambulatory phlebectomy: [laterality] leg, tributaries in [anatomic regions]

(List only the procedures actually performed; remove non-applicable lines.)

[Positioning, preparation, and sterile setup] (Describe patient positioning; skin prep agent; sterile draping; ultrasound probe preparation with sterile cover and gel.)

[Venous access] (Document access site with laterality and anatomic level; ultrasound-guided puncture technique; sheath size; confirmation of intraluminal position by ultrasound visualization and blood return; state that real-time ultrasound guidance was used.)

Vein and segment: [Laterality] [vein name] ([segment treated])

Device: [Catheter/fiber/device type]

Proximal endpoint: [Distance in cm distal to SFJ or SPJ]

Distal endpoint: [Anatomic landmark or level]

Treated length: [Total cm if tracked]

Tumescent Anesthesia

(Include this subsection only if tumescent anesthesia was used; otherwise omit entirely.)

Solution composition: [Components and concentrations]

Total volume infiltrated: [mL] (If exact volumes documented elsewhere, reference that location.)

Total lidocaine dose: [mg] ([mg/kg if available])

Technique: [Perivenous infiltration under ultrasound guidance]

Patient tolerance: [Tolerated well / issues encountered]

Ablation Technique and Parameters

(Include only the parameter set for the modality actually performed; omit all others.)

Radiofrequency ablation: [Generator/catheter model if tracked]; [Treatment method including cycles and segment length per cycle]; [Settings]; [Adjustments if any]

Endovenous laser ablation: [Wavelength]; [Fiber type]; [Power in watts and mode]; [Total energy in joules or energy density]; [Pullback method]; [Treated length]

Mechanochemical ablation: [Device]; [Sclerosant name, concentration, and volume if used]; [Treated segment]

Adhesive closure: [Product]; [Delivery catheter]; [Start point relative to junction]; [Injection protocol]; [Compression protocol if used]

Ambulatory Phlebectomy

(Include this subsection only if phlebectomy was performed; otherwise omit entirely.)

Pre-procedure marking: [Varicosities marked pre-procedure: yes / no]

Local anesthetic: [Agent and concentration]

Incision count: [Number] stab incisions on [laterality] extremity (Required for billing; flag as missing if not documented.)

Regions treated: [Anatomic regions of the leg with laterality]

Technique: [Technique description]

Closure/dressing: [Closure method and dressing applied]

Completion Ultrasound Assessment

Treated vein occlusion: [Closure/occlusion of treated vein with laterality confirmed: yes / no; description]

Junction and deep system assessment: [CFV or popliteal vein patency with laterality]; thrombus extension into deep system: [present / absent] (If present, document classification and immediate plan. This finding is required; prompt if not documented.)

Scan limitations: [If limited, document scope assessed; otherwise omit]

Image storage: [Images stored to PACS: yes / no]

Findings: [Brief description of treated pathology and any anatomic variants]

EBL: [Estimated blood loss]

Specimens: [None / description if tissue sent]

Complications: [None / description] (Must be documented explicitly, including "none" if none occurred.)

Tolerance: [Patient tolerance and hemodynamic stability]

Post-Procedure

[Disposition] (Briefly describe patient condition on completion, neurovascular status as appropriate, and disposition to home or recovery area.)

Dressings: [Wound care applied to incision/access sites]

Compression: [Type: bandage wrap / stocking / both]; [Compression strength in mmHg if known]; [Duration and schedule: continuous vs daytime only; number of days]

[Activity and recovery instructions] (Encourage ambulation; specify restrictions such as heavy lifting, prolonged standing, hot baths; return to work/driving guidance if provided.)

[Medications if applicable] (Analgesia plan; anticoagulation plan if relevant; antibiotics if prescribed with rationale.)

Follow-up visit: [Timing]

Duplex ultrasound: [Routine protocol / Risk-based protocol] (If risk-based, state that ultrasound is not routinely scheduled for asymptomatic patients.)

Return Precautions

Patient instructed to seek urgent evaluation for: signs of DVT (calf swelling, unilateral leg swelling); signs of PE (dyspnea, chest pain); bleeding not controlled with direct pressure; signs of infection at access or incision sites; severe or worsening pain; new numbness; or concerns for skin injury.