Interventional Radiology Procedure Note (General)

Date of Service: [Date of service]

Procedure Start Time: [Start time]

Location: [IR suite / OR / bedside / hybrid OR / other]

Procedure Type: [elective / urgent / emergent]

Referring Provider/Service: [Name and service]

Procedure(s) Performed

• [Procedure name with laterality and target organ/vessel]
• [Additional procedure if performed]

(List each procedure separately with clear clinical name, laterality, and anatomic target.)

Indication

[Indication and relevant clinical context]

(Include succinct rationale for the procedure. Reference pertinent prior imaging by study type and date without reproducing full reports.)

Post-Procedure Diagnosis

[Unchanged from pre-procedure diagnosis / Updated diagnosis: specify]

Operators

Primary Operator: [Name, credentials]; Attending Physician: [Name, credentials]; Assistant(s): [Name(s)]; Anesthesia Provider: [Name/role]

(Omit Assistant(s) and Anesthesia Provider lines if not applicable.)

Pre-Procedure Safety Verification

• Consent: [Informed consent obtained from patient / authorized representative] (State where consent is documented. If emergent and consent unobtainable, document the reason and basis to proceed.)
• Time-out: [Time-out performed confirming correct patient, procedure, and site/laterality] (If not performed, state why and what alternative safety measures were taken.)
• Site Marking: [Marked / Not applicable: internal organ or non-markable site / Not performed: reason]
• Antibiotic Prophylaxis: [Given: agent and timing / Not indicated]

Anesthesia and Sedation

Sedation level: [local anesthesia only / minimal sedation / moderate sedation / MAC / general anesthesia]

(If local anesthesia only, the above line is sufficient. If sedation was administered, include the following:)

• Sedation medications:
  • [Agent, dose, route]
• Sedation start time: [Time]; Sedation end time: [Time]
• Monitoring clinician: [Name/role]
• Local anesthetic: [Agent and total volume]
• Adverse events: [None / Description of hypoxia, hypotension, airway interventions]
• Reversal agents: [None / Agent and dose]

(If detailed sedation vitals are in a separate record, reference that record while documenting sedation type, time anchors, and significant events here.)

Technique

[Narrative description of the procedure]

(Include: patient positioning; skin preparation and antiseptic; imaging guidance modality; access site with laterality; access method; vessel or target accessed; sheath size for vascular cases. Describe key steps including catheter/wire manipulation, contrast injections and findings, interventions performed, device deployment, and hemostasis/closure method. Conclude with confirmation imaging and end-of-procedure findings. Describe what actually occurred rather than using boilerplate language.)

Devices and Implants

• Device type: [Drain / Stent / Catheter / Port / Coil / Filter / Other]; Size: [French / diameter / length]; Manufacturer/Model: [If available]; Lot/Serial/UDI: [If available]; Status: [Newly placed / Exchanged / Removed]; Final position: [Tip location or deployment site]

(Add additional devices as needed. If no devices were placed or left indwelling, state "None.")

Intraprocedural Medications

• [Medication: agent, dose, route, timing]

(Include non-sedation medications such as antibiotics, anticoagulants, thrombolytics, vasodilators, or intracavitary agents. Omit this section entirely if none beyond sedation and local anesthetic.)

Findings

[Significant imaging and procedural findings]

(Include target lesion/vessel status pre- and post-intervention, relevant anatomic variants, and endpoint confirmation such as restored flow, resolved extravasation, or correct catheter position.)

Specimens

• Type: [Core biopsy / FNA / Aspirate / Fluid]; Target site: [Site and laterality]; Samples: [Number of passes, needle gauge]; Destination: [Surgical pathology / Cytology / Microbiology]; Special handling: [If any]

(Add additional specimens as needed. If no specimens obtained, state "None.")

Estimated Blood Loss

[Numeric estimate in mL / Minimal, less than 10 mL]

Complications

[None immediate / Description of complication(s)]

(If complications occurred, describe what happened, timing, severity, interventions taken, patient status at note completion, and notifications made. Always include a complications statement.)

Contrast

Agent: [Name and concentration]; Volume: [Total mL]; Route: [IV / intra-arterial / intracavitary]; Reaction/Extravasation: [None / Description and management]

(State "None" for fluoroscopic/angiographic procedures where no contrast was used. For ultrasound-only procedures, omit this section.)

Radiation Exposure

• Reference air kerma (Ka,r): [mGy]
• Kerma-area product (PKA/DAP): [Gy·cm²]
• Peak skin dose: [mGy] (If available)
• Fluoroscopy time: [minutes]
• Acquisitions/runs: [Count]

(If dose thresholds were exceeded, document patient counseling and follow-up per institutional protocol. For ultrasound-only procedures, state "None (ultrasound guidance only)" or omit this section.)

Post-Procedure Condition and Plan

Condition: [Hemodynamic status, pain control, access site status and dressing, neurologic assessment if relevant]

Disposition: [IR recovery / PACU / ICU / Floor / Discharge]

• Monitoring: [Vital sign frequency, access/site checks, neuro checks if applicable]
• Activity: [Bedrest duration and restrictions]
• Anticoagulation/Antiplatelet: [Hold/restart timing]
• Device/Drain care: [Flush schedule, suction vs gravity, output monitoring]
• Medications: [Post-procedure analgesia, antibiotics, other orders]
• Follow-up: [Imaging type and timeframe, clinic follow-up, lab checks]
• Return precautions: [Fever, bleeding, increasing pain, neurologic changes, access site concerns]

(Include only applicable items. Reference standardized discharge instructions rather than duplicating content.)