What is Usually NOT Included in a Procedure Note
Procedure notes typically exclude patient opinions/perspectives, detailed informed consent discussions, conflicts of interest declarations, and patient-identifiable demographic information beyond what is clinically necessary.
Core Elements That ARE Included in Procedure Notes
Based on surgical case report guidelines, procedure notes should contain 1:
- Pre-intervention considerations - patient optimization measures, medication management, anticoagulation status 1
- Intervention details - specific procedures performed, equipment used (with manufacturer and model), surgical technique, operator experience level 1
- Intraoperative findings - relevant clinical observations, anatomical findings 1
- Peri-intervention considerations - anesthesia type, patient positioning, tourniquet use 1
- Immediate outcomes - blood loss, operative time, complications encountered 1
Elements Typically EXCLUDED from Procedure Notes
Patient Perspective and Subjective Experience
Patient perspectives on treatments received are documented separately, not within the procedure note itself 1. The SCARE guidelines specifically designate "Patient Perspective" as a distinct section separate from procedural documentation 1.
Informed Consent Process Details
The detailed informed consent discussion—including risks, benefits, alternatives explained to the patient—is documented in consent forms and pre-procedure notes, not the procedure note 1. The procedure note may reference that consent was obtained, but does not reproduce the entire consent conversation 1.
Administrative and Ethical Declarations
Conflicts of interest, funding sources, and institutional review board approvals are classified as "Additional Information" separate from procedural documentation 1. These elements appear in research publications but not in clinical procedure notes 1.
Excessive Patient-Identifiable Information
While basic demographics (age, sex, relevant medical history) are included 1, procedure notes should contain de-identified information and avoid unnecessary personal details like occupation, detailed social history, or information unrelated to the procedure 1.
Educational Commentary and Literature Review
Discussion of relevant literature, implications for clinical practice guidelines, and educational "take-away" lessons belong in case reports or educational documents, not procedure notes 1. The rationale for conclusions and hypothesis generation are similarly excluded 1.
Common Documentation Pitfalls
Avoid including subjective language that could be perceived as critical of the patient 2. Clinicians report modifying documentation language when notes are accessible to patients, with 58% changing language that could be perceived as critical 2.
Do not document preliminary or uncertain findings as definitive - diagnostic reasoning and alternative diagnoses considered should be clearly distinguished from final procedural findings 1.
Exclude billing and coding justifications from the clinical procedure note 3. While documentation must support billing, the explicit justification for charge codes belongs in billing documentation, not the clinical procedure record 3.