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Proposal and Goals:

We propose to create a standardized electronic procedure note that will replace all documentation for bedside procedures without sedation.

◦Makes notes legible and easily identified

◦Allows uniform tracking of metrics necessary to identify outcomes from a procedure (blood loss, specimens, post-procedure studies, complications)

2.The procedure note will be created in such a way as to allow specialized procedures to be added over time with minor customization to improve physician/nursing work flows and increase efficiency

◦Allows procedures to be sorted and tracked by type

◦Will be constructed to allow attaching CPT codes to patient charts via documentation

3. We propose using this procedure note to create a running database of all bedside procedures

◦Can be utilized by existing software (Qlik) to query all procedure notes to create large anonymized patient lists

Publication Date



Tracking and Improving Bedside Procedures Through Standardized Documentation, Abington Jefferson Health, Thomas Jefferson University, HOUSE STAFF QUALITY IMPROVEMENT AND PATIENT SAFETY POSTERS


Medicine and Health Sciences

Tracking and Improving Bedside Procedures Through Standardized Documentation