Foreign Body Removal Procedure Note

Date/Time: [Procedure start time – end time]

Procedure: Foreign Body Removal

Location: [Clinical setting and anatomic site with laterality]

Operator: [Name and credentials]

Indication: [Pre-procedure diagnosis or reason for removal]

Post-Procedure Diagnosis: [Diagnosis after procedure] (Update if different from indication; otherwise repeat indication.)

Pre-Procedure Assessment

• Anatomic site: [Location with laterality and relevant landmarks]; Depth: [superficial / subcutaneous / deeper]
• Wound characteristics: [Size/length, contamination level, infection signs, active bleeding]
• Suspected foreign body: [Material/type and estimated size if known]
• Risk modifiers: [Anticoagulants/antiplatelets, bleeding disorders, diabetes, immunosuppression, relevant allergies] (Include only if present; otherwise omit line.)
• Baseline neurovascular and functional exam: [Distal perfusion, motor function, sensation, tendon/ROM function] (Mandatory for extremity procedures. Document explicitly; do not auto-populate.)
• Imaging: [Modality, key findings, whether used for localization] (Include only if performed or if considered but not performed with rationale. Omit if not relevant.)

Informed Consent

[Verbal / Written] consent obtained from [patient / guardian] with capacity confirmed. The procedure, material risks, benefits, and alternatives were discussed, including: pain, bleeding, infection, scarring, retained foreign body or incomplete removal, damage to nearby structures (nerves, vessels, tendons), and possible need for additional procedures or referral. (If emergency and consent not obtainable, document why delay posed unacceptable risk.)

Time-Out Verification

Time-out performed immediately prior to the procedure confirming correct patient, correct procedure, correct site and laterality, allergies reviewed, and required equipment available. [Site marking performed / Site marking not applicable].

Preparation

[Sterile / Clean] technique. Skin prepped with [agent] and draped appropriately.

Anesthesia: [Agent and concentration], [volume/dose], via [local infiltration / field block / nerve block / topical] / No anesthesia used (If none, include brief rationale.)

Tourniquet: [Type and duration] / None

Procedural sedation: Documented in separate sedation record / Not used

Procedure

[Chronological narrative of technique] (Include: approach via existing wound or new incision; localization method; instruments used; dissection technique and extent of exploration; foreign body removal including number of fragments and whether removed intact; any fragmentation and retrieval efforts; irrigation with fluid type and volume; wound closure method or decision to leave open; dressing or splint applied. Approximately 5–12 sentences.)

(If procedure unsuccessful or aborted: State "Foreign body not removed," document reason, and include plan for imaging, referral, or return instructions.)

Findings and Outcome

• Removed foreign body: [Material, size in mm or cm, shape, intact vs fragmented]
• Removal confirmation: [Foreign body removed intact; wound explored without additional fragments visualized / Post-removal imaging confirms no retained radiopaque material / Retained foreign body cannot be excluded – include mitigation plan]
• Estimated blood loss: [Minimal / amount in mL]
• Patient tolerance: [Well tolerated / Poorly tolerated with details]
• Specimen disposition: [Retained by patient / Discarded per policy / Sent to pathology]

Complications: [No immediate complications / Complication: event, management, patient response, escalation if any]

Post-Procedure Exam

• Neurovascular/functional status: [Distal perfusion, motor function, sensation, ROM/tendon function] (Mirror baseline exam; mandatory for extremity procedures.)
• Wound appearance: [Description, hemostasis achieved]
• Pain reassessment: [Pain level and response]

(Omit this section for superficial procedures where functional change is not a concern.)

Disposition and Aftercare

• Wound Care: [Dressing type and change frequency, keep clean and dry, bathing guidance]
• Tetanus: Vaccination history: [known up-to-date / unknown / not up-to-date]; Wound type: [clean-minor / contaminated-tetanus-prone]; Action: [vaccine given / TIG given / none required with rationale]
• Antibiotics: [Agent, dose, duration, indication] / Not prescribed (Include rationale if prophylaxis might otherwise be expected.)
• Activity Restrictions: [Splinting, weight-bearing limits, work or sport restrictions as applicable]
• Follow-up: [With whom and timeframe]
• Return Precautions: Return for fever, increasing redness or swelling, increasing pain, purulent drainage, red streaking, numbness or weakness, worsening function, persistent foreign body sensation, uncontrolled bleeding, or any concern.

Authentication

[Signature, credentials, date/time]