Clinical template
Procedure note template with examples
A procedure note is a legal record of what was done, why, and what happened, written while the details are still true. The template below follows Scribeberry's Procedure Note structure: indication, technique, what was administered, patient response, complications, and what the patient was told to do next.
Procedure note
Ready to review- Visit details pulled in
- Letter drafted from the conversation
- Your review and signature
Key takeaways
- A procedure note proves indication, consent, technique, specimens, and outcome — it is a legal record, not an afterthought.
- Anaesthetic agent and volume, specimen destination, and post-procedure instructions are the fields most often missing.
- Scribeberry drafts the note from the encounter so those fields are prompted, not remembered.
What is a procedure note?
A procedure note is the contemporaneous written record of a clinical procedure: what was performed, the indication, consent, preparation and technique, instruments and medications used with doses, findings, specimens sent, complications or their absence, the patient's condition afterward, and the instructions and follow-up arranged. It serves three readers at once — the next clinician continuing care, the patient reading their record, and, if anything is ever questioned, the reviewer reconstructing what happened. A procedure note template exists so none of those elements depends on memory at the end of a clinic day.
This procedure note template matches the structure of Scribeberry's built-in Procedure Note. Copy the blank template into any EMR, or dictate the details immediately after the procedure and generate the note in this structure.
How to write a procedure note, step by step
- Name the procedure precisely, with site and laterality, and the date, time, location, and operator.
- State the indication in one or two lines: the finding or symptom that made this procedure the right next step.
- Record consent: what was discussed, the material risks explained, and who consented.
- Note preparation as performed: positioning, antiseptic technique, site confirmation or timeout, and anaesthesia or sedation with agent, dose, and route.
- Write the technique in the order it happened, with instrument and device sizes, medications administered, and volumes where relevant.
- Document findings and any specimens, with labelling and destination, and estimated blood loss for operative procedures.
- State complications plainly, or that there were none, and the patient's condition at the end of the procedure.
- Finish with post-procedure instructions, warning signs, and follow-up: who receives results, who acts on them, and when the patient is seen again.
Blank procedure note template
Copy this into your EMR, or use it as a Scribeberry custom template. Document consent, laterality, and a timeout where your setting requires them; 'no complications' should mean none occurred, not that the section was skipped.
Procedure note
Procedure performed: Date / time / location: Operator and assistants: Indication for the procedure: Consent (discussion, risks explained, consent obtained from): Relevant allergies / anticoagulation status: Preparation (positioning, sterile technique, timeout/site confirmation): Anaesthesia or sedation (agent, dose, route): Technique, step by step: Instruments, devices, or implants used (with sizes/lot where relevant): Medications administered during the procedure: Findings: Specimens sent (type, labelling, destination): Estimated blood loss / fluids: Complications or issues encountered (or 'none'): Patient response and condition at the end of the procedure: Post-procedure instructions given to the patient: Activity, wound-care, and medication instructions: Warning signs discussed and when to seek care: Follow-up plan and who receives the results:
Fictional patients
Every example on this page uses made-up names and findings. They are teaching material, not a substitute for college standards, institutional policy, or your own clinical judgment. Review every generated note before it enters the chart.
Example: knee joint aspiration and injection
Left knee, effusion with suspected crystal disease
52-year-old woman, Winnipeg clinic. Fictional.
Procedure: Left knee joint aspiration and intra-articular corticosteroid injection. Indication: Painful left knee effusion, 5 days, to exclude septic arthritis and crystal disease and to relieve pain. Consent: risks discussed including infection, bleeding, post-injection flare, and skin depigmentation; verbal consent obtained. Allergies: penicillin (rash). Anticoagulation: none. Technique: Patient supine, knee supported in slight flexion. Lateral suprapatellar approach. Skin prepped with chlorhexidine, sterile drape, timeout confirmed left side. Local anaesthesia: 2 mL lidocaine 1% subcutaneous. An 18-gauge needle was advanced into the suprapatellar pouch; 28 mL of cloudy yellow fluid was aspirated and sent for cell count, Gram stain, culture, and crystal analysis. Through the same needle, methylprednisolone 40 mg with 2 mL lidocaine 1% was injected. Needle withdrawn, sterile dressing applied. Findings: Cloudy inflammatory-appearing fluid, no blood. Patient tolerated the procedure well. No complications. Knee range improved immediately after aspiration. Post-procedure instructions: Rest the knee today, ice 15 minutes at a time, acetaminophen as needed. Explained that a steroid flare can occur in the next 24–48 hours and usually settles. Return sooner or present to urgent care for fever, spreading redness, or pain that sharply worsens after initially improving. Fluid results will be called to her within 2–3 days; family doctor copied. Follow-up in clinic in 3 weeks, sooner if results change management.
Who uses a procedure note, and when
Any clinician who performs a procedure — physicians, nurse practitioners, and trainees under supervision — writes a procedure note: emergency, family medicine, dermatology, hospital, and clinic settings alike.
- Minor surgical procedures: excisions, incision and drainage, suturing.
- Joint and soft-tissue injections and aspirations.
- Bedside procedures: paracentesis, thoracentesis, lumbar puncture, central lines.
- Gynecologic and dermatologic procedures including biopsies.
- Any procedure where consent, specimens, or complications may later be reviewed.
Documentation, privacy, and record-keeping in Canada
The procedure note is the contemporaneous legal record that the procedure was indicated, consented, performed correctly, and tolerated. Canadian regulators (provincial colleges, guided by CMPA advice) expect indication, consent discussion, technique, specimens, estimated blood loss where relevant, complications, and post-procedure instructions in every note. If it is not in the note, it is difficult to prove it happened — particularly consent and specimen handling.
Across Canada, clinical notes form part of the legal medical record. Provincial regulators expect entries that are contemporaneous, factual, and attributable; health information is handled under provincial privacy law (such as PHIPA in Ontario, the HIA in Alberta, and Law 25 in Quebec) and PIPEDA where it applies. Disclose the minimum necessary, with patient consent, and record amendments as amendments — never by overwriting the original entry.
Common mistakes that weaken a procedure note
- No consent discussion recorded before an invasive procedure.
- Missing specimen description or where it was sent.
- Anaesthetic agent, concentration, and volume omitted.
- No post-procedure instructions or follow-up arrangement.
- Complications described vaguely ('tolerated well') instead of factually.
- Counts, timeouts, or ultrasound guidance used but not documented.
The signing checklist
Before signing: Is the reason for the encounter explicit? Are negatives that change management recorded? Does every diagnosis have a plan with an owner and a date? Are results, counselling, and follow-up documented — or only intended?
Details that protect the patient and the record
- Indication first. A technically perfect note that never says why the procedure happened fails its main test.
- Laterality, site confirmation, and a timeout where required, written as done, not implied.
- Doses and routes for everything administered, including local anaesthetic; 'injected steroid' is not a dose.
- Specimens: what was sent, where, and who will receive and act on the results.
- Complications honestly, including 'none.' A difficult procedure documented plainly reads better than a smooth fiction.
- Post-procedure instructions and warning signs in the note, matching what the patient was actually told.
Generate the note while you dictate the details
Dictate the indication, technique, doses, and findings after the procedure and Scribeberry's Procedure Note drafts the full record in this structure. You review before Smart Push into Jane, Accuro, OSCAR, or any web EMR.
Procedure note vs operative note vs progress note
| Clinic procedure note | Operative note | Progress note mention | |
|---|---|---|---|
| Scope | One bedside or clinic procedure | A surgical operation, usually with an anaesthesia record | 'Procedure tolerated well' in a daily note |
| Technique | Step by step, instruments and doses | Full operative detail, assistants, counts, anaesthesia | Usually absent |
| Specimens | What was sent, where, who follows up | Pathology and cultures with disposition | Often missing |
| Aftercare | Instructions, warning signs, follow-up owner | Post-op orders and disposition | Generic |
The one-line progress note mention is where procedures disappear. If a needle, device, or specimen was involved, the encounter deserves the structured note, not a sentence.
Example 2: incision and drainage of a skin abscess
Flank abscess, community clinic
36-year-old man, Saskatoon clinic. Fictional.
Procedure: Incision and drainage of right flank cutaneous abscess. Indication: 4 cm fluctuant, painful abscess present 4 days, enlarging despite warm compresses; no fever. Consent: procedure, risks of bleeding, recurrence, scarring, and need for antibiotics explained; verbal consent obtained. Allergies: sulfonamides (hives). Anticoagulation: none. Diabetic: no. Technique: Patient positioned left lateral. Area prepped with chlorhexidine and draped. Field block with 6 mL lidocaine 1% with epinephrine. A 1 cm incision was made over maximal fluctuance; approximately 15 mL of purulent material drained and sent for culture. Loculations broken up gently with a curved haemostat, cavity irrigated with 60 mL sterile saline. Cavity left open with a light iodoform wick. Sterile dressing applied. Findings: Single cavity, no tracking, no foreign body. Patient tolerated the procedure well. No complications. Pain improved immediately after drainage. Post-procedure instructions: Keep the area clean and dry today; begin warm soaks tomorrow. Wick to be removed at the wound check. No antibiotics started given adequate drainage, no surrounding cellulitis beyond 1 cm, and no systemic features; this reasoning was discussed with the patient. Warning signs reviewed: spreading redness, fever, worsening pain, or red streaking means same-day reassessment. Wound check in 2 days with me; culture results will be called to him and copied to his family doctor.
Frequently asked questions
What should a procedure note include?
The procedure performed, indication, consent, relevant allergies and anticoagulation, preparation and technique, instruments and medications with doses, findings, specimens sent, complications or their absence, patient response, post-procedure instructions, and the follow-up plan.
How soon should a procedure note be written?
Immediately after the procedure, while doses, findings, and the patient's response are exact. Details reconstructed at the end of the day are where procedure notes lose accuracy, which is why many clinicians dictate the note before the next patient.
Does Scribeberry have a procedure note template?
Yes. Procedure Note is a built-in Scribeberry template that drafts indication, technique, instruments and medications administered, response, complications, post-procedure instructions, and follow-up from your dictation or recording.
Can I copy this into my EMR?
Yes. Paste the blank template into Jane, Accuro, OSCAR, TELUS, or any EMR template library, or keep it as a Scribeberry custom template so procedure notes are generated in this structure.
What must every procedure note contain?
Indication, consent, procedure and technique, anaesthesia, findings, specimens, complications, condition at completion, and post-procedure instructions with follow-up.
Should consent be in the procedure note or a separate form?
Both where your institution requires a form — but the note itself should still record that consent was obtained and what was discussed, because the note is the contemporaneous clinical record.
References
- Good practices in medical record keeping — Canadian Medical Protective Association (CMPA)
- Medical Records Documentation — practice standard — College of Physicians and Surgeons of Ontario (CPSO)
- Personal Health Information Protection Act (PHIPA) — Government of Ontario
- Healthcare Excellence Canada — Healthcare Excellence Canada
Examples on this page are fictional and for illustration only; they do not describe real patients. Templates reflect the corresponding built-in template in Scribeberry at the date above.
