Procedure Note: Structure and Sections
Minor office procedure or bedside intervention. Notermed's built-in Procedure Note produces the sections below from what is said during the visit. You read the draft, change anything you want changed, and sign it. Until you sign it, it is a draft and outside the record.
What the Procedure Note contains
9 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Procedure
- The name of the procedure performed
- 2
Indication
- The clinical indication or reason for the procedure
- 3
Consent
- Consent obtained, verbal or written
- Risks discussed
- 4
Operator & Assistant
- The clinician performing the procedure
- Any assistant
- 5
Technique
- The steps of the procedure, as narrated
- 6
Findings
- Findings during the procedure
- 7
Specimens
- Specimens collected
- Where they were sent
- 8
Complications
- Complications encountered
- 9
Post-procedure Plan
- Instructions given
- Wound care
- Monitoring
- Follow-up
A section nobody said anything about is left out of the draft rather than padded. You will not find "not discussed" filling a heading you never covered.
Questions about the Procedure Note
What sections does the procedure note contain?
Nine: Procedure, Indication, Consent, Operator and Assistant, Technique, Findings, Specimens, Complications, and Post-procedure Plan.
How does the technique section get written?
From the steps as they were narrated. If you talk through what you are doing, that is what the draft reports, in the order you said it.
What if there were no complications?
The complications section records the complications encountered, and a section nobody said anything about is left out of the draft rather than padded. If you want the note to record that there were none, say so out loud.
Does the note record consent?
It records that consent was obtained, verbal or written, along with the risks discussed, as they were stated in the room.
What holds true for your patient data
These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.
A BAA first
We sign a Business Associate Agreement with your clinic before any patient data is processed.
US servers only
Patient data is stored and processed only on servers in the United States.
Encrypted throughout
Recordings, transcripts and notes are encrypted in transit and at rest.
Never training data
Patient conversations are never used to train AI models.
Yours to sign
Every note is a draft until the clinician reviews it and signs it.
Structure reviewed
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
See the Procedure Note on one of your own visits
Bring a consultation. We will record it, show you the draft in this format, and tell you plainly if Notermed is not a fit yet.