Vasectomy Procedure Note

Date of Service: [Date of service]
Start Time: [Start time]
End Time: [End time]
Location: [Procedure location]
Operator: [Operator name and credentials]
Patient: [Patient name and identifier]

(Do not infer counseling content, consent status, time-out performance, laterality details, occlusion method, specimen decision, or PVSA plan—capture only what is explicitly stated in dictation. If any required element is missing, insert [Information needed: ...]. For complications, only state no immediate complications if explicitly documented. Maintain parallel left and right vas deferens structure; do not combine into a single narrative.)

Procedure Summary

• Procedure performed: Bilateral vasectomy
• Access technique: [no-scalpel / minimally invasive / incisional]
• Occlusion method: [Occlusion technique including cautery, fascial interposition, ligation/clips, open-ended approach, and which ends treated]
• Anesthesia: [local / local with oral anxiolytic / other]
• Estimated blood loss: [EBL in mL]
• Specimens: [sent to pathology / not sent per clinic protocol]
• Immediate complications: [none / complication and management]
• Disposition: [Disposition]

Indication

[Indication for elective permanent sterilization, including pertinent contextual factors such as prior scrotal surgery, anticoagulant use, or difficult anatomy if documented]

Counseling and Informed Consent

[Documentation of counseling provided, including: permanence of vasectomy, that sterility is not immediate and alternative contraception must continue until PVSA clearance, residual failure risk after clearance, alternatives to vasectomy, risks including hematoma/infection/acute pain/chronic scrotal pain/rare need for repeat procedure, post-procedure activity and ejaculation restrictions, and PVSA timing expectations]

Informed consent obtained: [yes / Information needed: consent status]. Written consent signed and in chart: [yes / Information needed: written consent].

[Interpreter used: language and interpreter identification] (Only include if applicable.)

[Federally funded sterilization: required consent form complete and waiting period satisfied] (Only include if applicable.)

Pre-Procedure Verification

[Allergies reviewed, correct patient/procedure/site verified, time-out performed immediately prior to procedure] (If not stated, insert [Information needed: pre-procedure verification].)

[Site marking status] (Include if applicable per local policy.)

[Baseline vitals if sedation or anxiolysis beyond local anesthesia used: BP, HR, RR, SpO2] (Only include if applicable.)

Anesthesia

• Type: [local / local with oral anxiolytic / other]
• Agent and concentration: [Agent, concentration, and whether buffered or mixed]
• Total volume: [Total mL]
• Injection sites: [Injection locations]
• Oral anxiolytic: [Medication and dose] (Only include if given.)
• Patient tolerance: [tolerated well / tolerance concerns]

Procedure Details

[Access technique narrative: number and location of skin opening(s), closure method (sutures/adhesive/left open), dressing applied]

Left Vas Deferens

• Palpation and isolation: [Vas palpated and isolated; note any difficulty]
• Method of isolation: [ring clamp / vas clamp / other]
• Division: [Vas divided]
• Segment excised: [yes, approximate length / no]
• Occlusion method:
  • Mucosal cautery: [testicular end / abdominal end / both / not performed]
  • Fascial interposition: [testicular end / abdominal end / both / not performed]
  • Open-ended technique: [yes, testicular end left open / no]
  • Clips or ligatures: [type and material / none]
• Ends returned to scrotum: [yes / details]
• Hemostasis: [confirmed / measures taken]

Right Vas Deferens

• Palpation and isolation: [Vas palpated and isolated; note any difficulty]
• Method of isolation: [ring clamp / vas clamp / other]
• Division: [Vas divided]
• Segment excised: [yes, approximate length / no]
• Occlusion method:
  • Mucosal cautery: [testicular end / abdominal end / both / not performed]
  • Fascial interposition: [testicular end / abdominal end / both / not performed]
  • Open-ended technique: [yes, testicular end left open / no]
  • Clips or ligatures: [type and material / none]
• Ends returned to scrotum: [yes / details]
• Hemostasis: [confirmed / measures taken]

Bilateral completion and laterality verification: [Bilateral completion confirmed; laterality verified by testicular movement with traction / other method] (If not stated, insert [Information needed: laterality verification].)

[Anatomic anomalies, difficult exposure, or deviations from planned technique] (Only include if documented.)

Specimens

[Vas segments sent to pathology: labeled left and right, destination] or [Vas segments not sent per clinic protocol] (Must be documented explicitly even when not sent.)

Complications

[No immediate complications] or [Complication(s) with description and actions taken] (Only document "no immediate complications" if explicitly stated; otherwise insert [Information needed: complications].)

Post-Procedure Condition and Instructions

Condition: [Patient condition at end of procedure]. Disposition: [Disposition].

Verbal and written post-procedure instructions provided covering: wound care and dressing, scrotal support and ice application, activity and lifting restrictions, pain management, resumption of sexual activity and ejaculation, and warning signs requiring clinic contact.

PVSA Follow-Up Plan

• Contraception continuation: Patient instructed to continue alternative contraception until PVSA confirms clearance: [yes / Information needed: contraception instruction]
• Target timing for first PVSA: [Weeks post-procedure and/or target date]
• Specimen collection instructions reviewed: [yes / Information needed: collection instructions]
• Clearance criteria: [Clearance criteria used by this practice]
• Plan if sperm persist: [Repeat PVSA timing, continued contraception, consideration of repeat procedure]
• Results communication: [How and when results will be communicated to patient]

Operator Signature

Electronically signed by: [Operator name and credentials] on [Date] at [Time]