ALL PROCEDURES

1. Preprocedure note, to include:

   • Procedure requested

   • Indication for procedure

   • Directed history and physical: depends on procedure. For example, for aortogram and runoff, ankle-brachial indices are mandatory, but would not be necessary for a TIPS

   • Relevant labs: PT/PTT, creatinine, platelets at minimum, others as indicated for specific procedures

   • Allergies, including what form the allergic reaction took (hives, anaphylaxis)

   • NPO status

   
   

   For conscious sedation:

   • Heart/Lung exam (NB: at Wishard these must be done and documented by the physician)

   • Mental status

   • Physical deformities that might affect airway patency

   • Prior problems with anesthesia or sedation

   • Indication for conscious sedation

   
   

2. Informed consent, witnessed, dated and timed

3. Procedure note, using standard format (dictation follows same format):

   • Procedure

   • Physicians

   • Complications

   • Contrast (type and volume)

   • Medications

   • Findings

   • Plan

   • Comments

     1. Procedure note must indicate IR plan (clinic F/U, scheduled tube change, etc). When making final inpatient visit, IR must indicate that IR is signing off.

     2. If patient's condition is not stable or changed during the IR procedure, the note must document condition in which patient returned to floor, the reason for changes, and with whom these changes were discussed.

     3. Final note must indicate who (SPECIFICALLY) will provide follow-up.

4. Pre- and Intra-procedure Orders, dated and timed

5. Post Procedure Orders: Used preprinted orders whenever possible. Time and date required.

6. Post-Op check note (all inpatients undergoing conscious sedation/major procedure and same day surgery patients)

Procedures Involving Conscious Sedation

Above, plus:

• Pre-sedation flow sheet, signed by MD

• Intra-procedure flow sheet, signed by MD

• Post-procedure flow sheet, signed by MD

• For outpatients, Discharge Sheet, signed by MD

All Outpatients and Patients with Tubes (Drains, Nephrostomy, Biliary, etc)

The H&P and procedural note should be COPIED and the copy placed in the outpatient chart. If no chart exists, a new one should be made. Any time a new tube is placed, a chart should be made at the time of discharge.

Patients who undergo intervention should have a follow up appointment scheduled prior to their discharge from the hospital. To schedule an outpatient visit, a member of IR must speak to the patient and give him/her a card with the time and date of the appointment. The appointment must be placed in the scheduling book and/or computer.

All patients with tunneled catheters and G-tubes need to return in 7-10 days for suture removal