Student Procedure Note (Observed/Assisted)

Procedure: [Procedure name with side/site/level as applicable]

Date/Time: [Date and time of procedure]

Location: [ED / ICU / bedside / procedure room / other]

Indication: [Brief clinical rationale]

Team Members and Supervision

• Primary operator: [Name, credentials]
• Student: [Student name] — [observed / assisted / performed portions]; [Brief description of student tasks]
• Supervising clinician: [Name, credentials]; [present in room for entire procedure / present for key/critical portions and immediately available throughout] (Use precise supervision language; avoid vague terms like "available.")
• Other participants: [Names and roles] (Include only if relevant.)

Pre-Procedure Assessment

(Include this section only when factors materially influenced the approach or risk; omit entirely for routine low-risk procedures if documented elsewhere.)

• Allergies: [Latex / antiseptic agents / local anesthetics / none relevant]
• Anticoagulation/bleeding risk: [Anticoagulants and status; pertinent labs with values and dates]
• Anatomic considerations: [Body habitus, prior surgeries, contractures, scoliosis, or other relevant factors]
• Imaging reviewed: [Relevant imaging and key findings]

Consent

[Informed consent obtained from patient / from surrogate (relationship) / not obtained due to emergent procedure with implied consent: (specific reason)]. Risks, benefits, and alternatives were discussed. [Patient / surrogate] demonstrated understanding and agreed to proceed. (Do not leave blank; explicitly document consent status.)

Time-Out

• [Time-out performed immediately prior to procedure with team present / Time-out not performed: (specific reason)]
• Patient identity: [Two identifiers confirmed]
• Procedure and site/side/level: [Verified]
• Patient positioning: [Verified]
• Allergies: [Reviewed]
• Equipment availability: [Verified]
• Concerns/discrepancies: [No unresolved concerns / Discrepancies resolved: (brief description)]

Anesthesia/Analgesia

[None / Local: (agent, concentration, volume, route) / Regional block: (type, agent, dose) / Sedation: (agent(s) and dosing; or reference separate sedation record)] (If no anesthesia was used, state "None" explicitly. Omit section only if truly not applicable.)

Technique

[Concise narrative: patient position; sterile preparation (antiseptic agent) and draping; approach (landmark-based or image-guided with modality); access method with anatomic location; number of attempts if more than one; key confirmations (e.g., flashback, free flow, ultrasound visualization, opening pressure); any deviations from standard technique with rationale; hemostasis achieved; dressing applied; patient tolerance if directly observed.]

Findings and Results

• Outcome: [Successful / Unsuccessful: (reason and next steps)]
• Quantified results: [Volume removed with color/character; opening pressure; device placement confirmation; other procedure-specific outcomes]
• Estimated blood loss: [Numeric estimate in mL / Minimal] (Include only if clinically relevant.)

Specimens and Devices

(Include only when specimens were collected or devices were placed/removed.)

• Specimens: [What collected; anatomic source with laterality; destination lab; tests ordered; labeled per protocol]
• Devices: [Device type and size; site; depth/length; securing method; confirmation method]

Complications

[None / Description including timing, severity, immediate management, patient response, and any change in disposition or escalation] (Do not leave blank; state "None" explicitly if no complications.)

Post-Procedure

• Immediate condition: [Stable / Unstable] — [Supporting observations: vital signs, mental status, site inspection]
• Post-procedure orders: [Imaging, labs, site check frequency, monitoring parameters]
• Patient instructions: [Wound care, activity restrictions, return precautions]
• Disposition: [Remained in unit / Returned to room / Transferred to (location)]

Student Statement

This note was authored by [Student name], medical student. I [observed / assisted with / performed portions of] this procedure as described above under direct supervision.

Supervisor Attestation

[I have reviewed the student's documentation and it accurately reflects the procedure performed. I was (present for entire procedure / present for key/critical portions and immediately available throughout). Findings, technique, and results as documented are accurate. Edits/clarifications: (if needed).] (Supervisor must actively review and confirm accuracy and level of presence before signing.)