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Document a bedside or surgical procedure

The Procedure note template records the procedure, the consent and the safety time-out together. When you sign it, CollabKare saves the procedure, the consent, the signed note and (if you entered a CPT code) the charge in one step, so they can never get out of step with each other.

Before you start​

Open the patient's chart and go to Documentation (Documentation Hub). Choose the Procedure note template.

Steps​

  1. Enter the Procedure name and, if you know it, the CPT code (for example, 36556 for a central venous catheter).
  2. Record the body site and laterality (left, right, bilateral, midline, or not applicable) and the indication.
  3. Record Consent: written, verbal, or emergency.
  4. Record Site marking: marked, not required (bedside non-invasive procedures), or not possible because of an emergency.
  5. Record the Time-out:
    • Choose Performed and list everyone who took part, separated by commas — for example Dr Rao (performer), RN Priya (circulating).
    • A time-out can be skipped only for bedside, non-invasive procedures where site marking is not required, or in an emergency.
  6. Complete the technique, anesthesia, findings, estimated blood loss, specimens, complications (or None) and the patient's condition afterwards.
  7. Click Sign. If anything required is missing, the template lists it before saving.

What happens next​

  • The procedure appears in the chart with the performer and time-out details, and the consent is stored with it.
  • If you entered a CPT code, a procedure charge goes to Charge review. If you are a resident, it waits for your attending's cosign first.

Tips / Troubleshooting​

  • "Time-out participants" missing: you chose Performed but did not name who took part.
  • "Time-out — only bedside, non-invasive procedures… may skip it": either record the time-out or change site marking to not required if that is accurate.