procedure-note-template

name	procedure-note-template
description	Generates procedure documentation templates pre-populated from FHIR data including patient demographics, indication, relevant labs, allergies, pre-procedure verification, sedation documentation, and complications checklist. Use when user asks to "write a procedure note", "document a procedure", "procedure template", "create procedure documentation", mentions "central line note", "intubation note", "LP note", or needs structured procedure documentation. Do NOT use for surgical operative reports, SOAP notes, progress notes, or discharge documentation.
metadata	{"author":"LangCare","version":"1.0.0","mcp-server":"langcare-mcp-fhir","category":"documentation"}

Procedure Note Template

Overview

Generate pre-populated procedure documentation templates from FHIR data. Pull patient demographics, procedure indication from active conditions, relevant pre-procedure labs (coagulation studies, platelets, hemoglobin), allergy list, and current anticoagulant status. Include required elements: informed consent verification, time-out documentation, procedure details, specimen handling, complications, and post-procedure orders. Support common bedside procedures: central venous catheter, arterial line, intubation, lumbar puncture, paracentesis, thoracentesis, chest tube, foley catheter, and NG tube.

FHIR Resources Used

Resource	Purpose	Key Fields
Patient	Demographics for note header	name, birthDate, gender, identifier
Condition	Procedure indication	code, clinicalStatus
Observation	Pre-procedure labs (coags, CBC), vitals	code, value[x], effectiveDateTime
AllergyIntolerance	Allergy check (esp. latex, iodine, lidocaine)	code, reaction, clinicalStatus
MedicationRequest	Anticoagulant status, sedation orders	medicationCodeableConcept, status, dosageInstruction
MedicationAdministration	Sedation medications given	medicationCodeableConcept, dosage, effectiveDateTime
Consent	Informed consent status	status, scope, dateTime
Procedure	Create procedure record	code, status, performedDateTime, outcome, complication

Instructions

Step 1: Retrieve Patient Demographics

Tool: fhir_read
resourceType: "Patient"
id: "[patient-id]"

Extract: name, DOB, age, gender, MRN for procedure note header and patient identification band verification.

Step 2: Identify Procedure Indication

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&clinical-status=active"

Match the stated procedure to an active condition as the indication. Common mappings:

• Central line: difficult IV access, need for vasopressors, TPN, prolonged IV antibiotics
• Arterial line: hemodynamic instability, frequent ABG monitoring
• Intubation: respiratory failure, airway protection
• Lumbar puncture: meningitis workup, subarachnoid hemorrhage evaluation
• Paracentesis: ascites (tense, diagnostic)
• Thoracentesis: pleural effusion (diagnostic or therapeutic)
• Chest tube: pneumothorax, hemothorax, empyema
• Foley catheter: urinary retention, strict I&O monitoring, perioperative
• NG tube: bowel obstruction, GI decompression, medication administration

Step 3: Pull Pre-Procedure Labs

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=laboratory&code=http://loinc.org|5902-2,http://loinc.org|6301-6,http://loinc.org|777-3,http://loinc.org|718-7,http://loinc.org|3173-2&_sort=-date&_count=20"

Critical pre-procedure LOINC codes:

• 5902-2: PT (Prothrombin time)
• 6301-6: INR
• 3173-2: aPTT (Activated partial thromboplastin time)
• 777-3: Platelet count
• 718-7: Hemoglobin
• 4544-3: Hematocrit

Flag if:

• INR > 1.5 (relative contraindication for most invasive procedures)
• Platelets < 50,000 (increased bleeding risk)
• Platelets < 20,000 (contraindication without transfusion)
• aPTT > 1.5x control
• Hemoglobin < 7 (consider transfusion before elective procedure)
• Labs > 24 hours old (recommend recheck)

Step 4: Check Allergies

Tool: fhir_search
resourceType: "AllergyIntolerance"
queryParams: "patient=[patient-id]&clinical-status=active"

Flag procedure-relevant allergies:

• Latex: Use non-latex gloves, equipment
• Iodine/Betadine: Use chlorhexidine for skin prep
• Chlorhexidine: Use betadine for skin prep
• Lidocaine/local anesthetics: Use alternative anesthetic, allergy consult
• Adhesive/tape: Use alternative securement
• Heparin (HIT): Avoid heparin-coated catheters and flushes

Step 5: Check Anticoagulant Status

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=active&category=http://terminology.hl7.org/CodeSystem/medicationrequest-category|inpatient"

Check active medications for anticoagulants and antiplatelets:

• Heparin drip: Check if held, last aPTT value
• Enoxaparin: Timing of last dose (hold 12h for prophylactic, 24h for therapeutic)
• Warfarin: Current INR
• DOACs (apixaban, rivarelbán, edoxaban): Timing of last dose (hold 24-48h)
• Clopidogrel, prasugrel, ticagrelor: Document if held
• Aspirin: Generally continued for most bedside procedures

Step 6: Check Consent Status

Tool: fhir_search
resourceType: "Consent"
queryParams: "patient=[patient-id]&status=active&scope=treatment"

If no procedure-specific consent found, flag: "INFORMED CONSENT: NOT DOCUMENTED -- obtain before proceeding."

Step 7: Pull Pre-Procedure Vitals

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=vital-signs&_sort=-date&_count=10"

Document baseline vitals before procedure.

Step 8: Assemble Procedure Note Template

PROCEDURE NOTE
===============
Patient: [name] | MRN: [mrn] | DOB: [dob] (Age: [age]) | Sex: [gender]
Date/Time: [procedure datetime]
Procedure: [procedure name]
Operator: [Flag: "Enter operator name and credentials"]
Supervising Physician: [if applicable]
Service: [service]

INDICATION
----------
[Condition from Step 2 with ICD-10 code]

INFORMED CONSENT
----------------
[Consent status from Step 6]
Risks, benefits, and alternatives discussed with: [patient / surrogate]
Consent signed: [date/time or "REQUIRED"]

ALLERGIES
---------
[List with procedure-relevant flags]

PRE-PROCEDURE VERIFICATION (TIME-OUT)
--------------------------------------
- [ ] Correct patient (two-identifier verification)
- [ ] Correct procedure confirmed
- [ ] Correct site/laterality marked (if applicable)
- [ ] Informed consent obtained
- [ ] Relevant labs reviewed:
      PT/INR: [value] ([date]) [FLAG if abnormal]
      Platelets: [value] ([date]) [FLAG if abnormal]
      Hemoglobin: [value] ([date]) [FLAG if abnormal]
      aPTT: [value] ([date]) [FLAG if abnormal]
- [ ] Anticoagulant status: [status from Step 5]
- [ ] Allergies reviewed: [summary]
- [ ] Equipment and supplies verified

PRE-PROCEDURE VITALS
---------------------
HR: [hr] | BP: [sys]/[dia] | RR: [rr] | SpO2: [spo2]% on [O2]

SEDATION / ANESTHESIA
----------------------
[Flag: "Complete if conscious sedation used"]
Sedation type: [none / local only / moderate sedation / deep sedation]
Medications administered:
  - [Drug] [dose] [route] [time] [Flag: "Enter"]
  - [Drug] [dose] [route] [time] [Flag: "Enter"]
Pre-sedation assessment: ASA class [I-V], Mallampati [I-IV], NPO status [hours]
Monitoring: Continuous pulse oximetry, cardiac monitor, ETCO2 (if applicable)

PROCEDURE DETAILS
-----------------
[Flag: "Operator to complete procedure details"]
Position: [supine / lateral decubitus / sitting / Trendelenburg]
Skin prep: [chlorhexidine / betadine] [Note allergy-based selection]
Draping: Sterile draping applied
Anesthesia: [lidocaine X% / bupivacaine X%] [volume] mL infiltrated to [site]
Technique: [Description of procedure steps]
Site: [anatomical location, laterality]

[Procedure-specific fields -- see references/procedure-documentation.md]

SPECIMENS
---------
[If applicable]
Type: [fluid / tissue / culture]
Sent to: [lab / microbiology / cytology / pathology]
Tests ordered: [cell count, culture, protein, glucose, LDH, cytology, etc.]
Labeled: [Yes -- two-identifier verification]

ESTIMATED BLOOD LOSS
--------------------
[volume] mL

COMPLICATIONS
-------------
[None / describe]
[Procedure-specific complication checklist -- see references/procedure-safety.md]

POST-PROCEDURE
--------------
Patient tolerated procedure: [well / with complications]
Post-procedure vitals: HR [hr] | BP [sys]/[dia] | SpO2 [spo2]%
Post-procedure imaging ordered: [CXR for central line/chest tube / none]
Post-procedure orders:
  - [Site check q[interval]]
  - [Dressing change instructions]
  - [Activity restrictions]
  - [Lab follow-up]

DISPOSITION
-----------
Patient returned to: [floor / ICU / recovery]
Attending notified: [Yes/No]

Step 9: Create Procedure Resource in FHIR

Tool: fhir_create
resourceType: "Procedure"
resource: {
  "resourceType": "Procedure",
  "status": "completed",
  "code": {
    "coding": [{
      "system": "http://www.ama-assn.org/go/cpt",
      "code": "[CPT-code]",
      "display": "[procedure-name]"
    }]
  },
  "subject": {"reference": "Patient/[patient-id]"},
  "encounter": {"reference": "Encounter/[encounter-id]"},
  "performedDateTime": "[procedure-datetime]",
  "performer": [{
    "actor": {"reference": "Practitioner/[practitioner-id]"}
  }],
  "reasonReference": [{"reference": "Condition/[indication-condition-id]"}],
  "outcome": {
    "coding": [{
      "system": "http://snomed.info/sct",
      "code": "385669000",
      "display": "Successful"
    }]
  },
  "note": [{"text": "[brief procedure summary]"}]
}

Common CPT codes:

• 36556: Central venous catheter insertion (non-tunneled)
• 36620: Arterial line insertion
• 31500: Intubation, endotracheal
• 62270: Lumbar puncture
• 49083: Paracentesis
• 32555: Thoracentesis
• 32551: Chest tube insertion
• 51702: Foley catheter insertion
• 43752: NG tube insertion

Examples

Example 1: Central Line Placement

User says: "Procedure note for central line placement on patient 11111."

Actions:

1. fhir_read Patient/11111. Returns: James Torres, DOB 1955-06-30, Male, MRN-11111.
2. fhir_search Condition active. Returns: Septic shock (R65.21), pneumonia (J18.9), T2DM, CKD4.
3. fhir_search Observation labs (coags, CBC). Returns: INR 1.2, platelets 188k, Hgb 9.8, aPTT 28.
4. fhir_search AllergyIntolerance. Returns: Latex allergy (urticaria). Flag: USE NON-LATEX EQUIPMENT.
5. fhir_search MedicationRequest anticoagulants. Returns: Heparin drip active -- held 2 hours ago, aPTT at hold was 55.
6. fhir_search Observation vitals. Returns: HR 105, BP 88/52 on norepinephrine, SpO2 96% on 4L NC.

Result:

PROCEDURE NOTE
===============
Patient: James Torres | MRN: MRN-11111 | DOB: 1955-06-30 (Age: 68) | Sex: Male
Procedure: Central venous catheter insertion (non-tunneled)

INDICATION: Septic shock requiring vasopressor administration (R65.21)

ALLERGIES
** LATEX ALLERGY (urticaria) -- USE NON-LATEX GLOVES AND EQUIPMENT **

PRE-PROCEDURE VERIFICATION
- Labs: INR 1.2 [OK] | Platelets 188k [OK] | Hgb 9.8 [OK] | aPTT 28 [OK]
- Anticoagulant: Heparin drip HELD 2h ago, aPTT at hold: 55
- Consent: [VERIFY]

PRE-PROCEDURE VITALS
HR: 105 | BP: 88/52 (on norepinephrine) | SpO2: 96% on 4L NC

[Procedure details: operator to complete -- site, technique, number of attempts,
 catheter type/size, line placement confirmation method, post-procedure CXR ordered]

Example 2: Lumbar Puncture

User says: "Generate LP procedure note template for patient pt-222, meningitis workup."

Actions:

1. fhir_read Patient/pt-222. Returns: Emily Park, DOB 1990-03-22, Female.
2. fhir_search Condition. Returns: Fever of unknown origin (R50.9), headache (R51.9), nuchal rigidity (R29.1).
3. fhir_search Observation labs. Returns: INR 1.0, platelets 245k, Hgb 12.8, WBC 18.5.
4. fhir_search AllergyIntolerance. Returns: NKDA.
5. fhir_search MedicationRequest. Returns: No anticoagulants active.
6. fhir_search Observation vitals. Returns: T 39.2C, HR 110, BP 128/78, SpO2 99% RA.

Result: Pre-populated LP template with indication (meningitis workup), normal coags confirmed, no allergy concerns, specimen handling section pre-filled (tube 1: cell count/diff, tube 2: glucose/protein, tube 3: Gram stain/culture, tube 4: hold for additional studies), opening pressure documentation field, post-LP instructions (flat 1-2 hours, monitor for headache).

Troubleshooting

Pre-procedure labs are older than 24 hours

• Flag prominently: "Labs dated [date] -- [X] hours old. Consider recheck before procedure if clinically indicated."
• For INR and platelets, 24-48 hours is generally acceptable if no interval events (bleeding, transfusion, new anticoagulation).
• For hemoglobin in actively bleeding patients, recommend point-of-care testing.

Consent resource not found in FHIR

• Consent resources are not universally implemented in FHIR servers. Many systems store consent in paper or scanned documents.
• Search DocumentReference for scanned consent: fhir_search DocumentReference with patient=[id]&type=http://loinc.org|59284-0 (LOINC 59284-0 = Consent document).
• If not found, prominently flag: "INFORMED CONSENT STATUS: UNABLE TO VERIFY IN ELECTRONIC RECORD -- confirm paper consent before proceeding."

Procedure-specific CPT code not in standard list

• Use SNOMED CT coding as an alternative: system: "http://snomed.info/sct".
• Common SNOMED codes: 233573008 (central line), 52765003 (intubation), 277762005 (lumbar puncture), 86088003 (paracentesis), 91602002 (thoracentesis).
• If no standard code matches, use code.text with the procedure name as free text.

Related Skills

• soap-note-generator - For documenting the encounter containing the procedure
• progress-note-writer - For post-procedure daily documentation
• lab-result-interpreter - For interpreting pre-procedure lab values
• preoperative-lab-checklist - For verifying all required pre-procedure labs are current