Flexible Bronchoscopy Procedure Note

Patient: [Patient name and MRN]

Date of Birth: [Date of birth]

Date of Procedure: [Date]

Start Time: [Start time] End Time: [End time]

Location: [Bronchoscopy suite / ICU / OR / other location]

Bronchoscopist: [Name and credentials]

Assistant(s): [Assistant name(s) and role(s)]

Procedure

Flexible bronchoscopy via [oral / nasal / ETT / tracheostomy] route with [BAL (site) / bronchial washings / bronchial brushings (site) / endobronchial biopsy (site) / transbronchial biopsy (site) / TBNA (station) / therapeutic intervention (describe)]. (List all interventions performed in a single sentence with target sites noted parenthetically.)

Indication

[Clinical indication: symptoms, imaging findings, suspected diagnosis, or therapeutic need]

Pre-Procedure Diagnosis: [Working diagnosis]

Post-Procedure Impression: [Immediate impression based on visual findings] (Describe observations rather than speculating if diagnosis is not yet determinable.)

Consent

Informed consent obtained from [patient / surrogate (relationship)] with discussion of risks, benefits, and alternatives, including [bleeding / pneumothorax / hypoxemia / sedation-related adverse events]. [Reference to signed consent form if applicable.] (Include only risks actually discussed.)

Time-Out

Time-out performed immediately prior to the procedure confirming correct patient, procedure, allergies, and bleeding risk considerations.

Pre-Procedure Assessment

Allergies: [Relevant allergies or NKDA]

Bleeding Risk: [Anticoagulants/antiplatelets and status; platelet count/INR if relevant]

Airway Status: [Spontaneous breathing / mechanical ventilation; ETT/trach size if applicable; baseline oxygen requirement]

NPO Status: [NPO duration]

Pre-Procedure Vitals: [BP, HR, SpO₂]

(Omit any elements not documented or not clinically relevant.)

Sedation and Anesthesia

[Sedation/anesthesia per anesthesia record.] (Use if anesthesia provided by separate team.)

[Sedation type] sedation administered by bronchoscopist with [medications, doses, routes]. [Independent trained observer present: yes/no]. (Use if bronchoscopist administered sedation; reference sedation flowsheet for detailed timestamps.)

Topical Anesthesia: [Agent] via [nebulized / spray-as-you-go / topical gel], total [dose in mg] ([mg/kg if available]) (Always document topical anesthesia administered by bronchoscopist; do not infer doses not explicitly recorded.)

Monitoring

Continuous [pulse oximetry / HR / BP at intervals / ECG] with oxygen delivered via [nasal cannula / face mask / HFNC / mechanical ventilation at settings]. [Clinically significant events and management if any.] (Do not duplicate detailed vitals if recorded in separate flowsheet.)

Procedure Details

Position: [Patient position]

Route: [Oral / nasal / via ETT / via tracheostomy] with [bite block / other adjuncts]

Guidance: [Fluoroscopy / navigation / ROSE / none]

Bronchoscope: [Type/model] (Include if documented.)

Sequence: [Order of sampling and interventions] (Document when order affects specimen quality, e.g., BAL before biopsy.)

(If airway survey only with no sampling, state: "Airway survey only; no specimens collected.")

Airway Findings

Upper Airway and Larynx

[Vocal cord mobility, edema, lesions, secretions, aspiration evidence] (Omit this subsection if upper airway not visualized.)

Trachea and Carina

[Patency, caliber, carina sharpness, malacia, erythema, lesions]

Right Bronchial Tree

• RUL: [Mucosa; secretions: none / scant / moderate / copious (mucoid / purulent / bloody); lesions with location and percent obstruction; narrowing; visualization limitations]
• RML: [Same elements]
• RLL: [Same elements]

Left Bronchial Tree

• LUL: [Mucosa; secretions: none / scant / moderate / copious (mucoid / purulent / bloody); lesions with location and percent obstruction; narrowing; visualization limitations]
• Lingula: [Same elements]
• LLL: [Same elements]

(Do not state "normal" unless region was visualized and examined. Document limitations with reasons.)

Interventions and Specimens

BAL

• Site: [Lobe/segment]
• Volumes: [Volume instilled] in [number] aliquots; [volume returned]
• Processing: [First aliquot pooled / discarded per protocol]
• Tests ordered: [Cell count/differential, bacterial culture, AFB, fungal, viral, cytology, other]

Bronchial Washings

• Site: [Lobe(s) / diffuse]
• Volume: [Instilled/returned if recorded]
• Tests ordered: [Culture(s), cytology, other]

Bronchial Brushings

• Site: [Lobe/segment]
• Method: [Conventional / protected brush]
• Passes: [Number]
• Bleeding: [None / mild / moderate / severe]; [hemostasis method if needed]
• Tests ordered: [Cytology, microbiology, other]

Endobronchial Biopsy

• Site: [Lobe/segment, specific location]
• Samples: [Number of biopsies]
• Bleeding: [None / mild / moderate / severe]; [hemostasis method]
• Tests ordered: [Pathology, other]

Transbronchial Biopsy

• Site: [Lobe/segment]
• Guidance: [Fluoroscopy: yes / no]
• Samples: [Number of biopsies]
• Bleeding: [None / mild / moderate / severe]; [hemostasis method]
• Tests ordered: [Pathology, microbiology, other]

TBNA

• Station: [Nodal station or target]
• Needle: [Gauge and type]
• Passes: [Number]
• ROSE: [Used with preliminary assessment / not used]
• Tests ordered: [Cytology, flow cytometry, microbiology, molecular, other]

Therapeutic Interventions

[Mucus plug removal / clot evacuation / foreign body removal / hemostatic agent application / airway stent / other] with [method/devices] and [outcome]. (Include only if therapeutic intervention performed.)

[Intervention considered but not performed: reason] (Include only if applicable, e.g., "Transbronchial biopsy deferred due to anticoagulation.")

Specimens labeled at bedside with two patient identifiers per institutional policy.

Complications and Tolerance

Complications: [None / specific complication(s) with severity and management]

EBL: [Minimal / quantified estimate]

Tolerance: [Patient tolerated procedure well / description with objective details if concerning events occurred]

Post-Procedure Plan

Condition: [Mental status relative to baseline; oxygen requirement; hemodynamic stability]

Recovery: [Location and level of care]

Diet: [NPO until gag reflex returns / other instructions]

Imaging: [CXR timing / symptom-triggered approach with rationale] (Particularly relevant after transbronchial biopsy.)

Medications: [Anticoagulant/antiplatelet restart timing; antibiotics if indicated]

Follow-Up: [Who will review results; expected turnaround; communication plan; contingent next steps]

Attestation

[Bronchoscopist signature/attestation]

[Images/video saved to institutional archive/PACS.] (Include only if applicable.)