Here’s a sample of my bronchoscopy note template in case anyone is interested in creating a “smart phrase” in their electronic health record. The “< >” indicates pre-populated drop down menus with the listed options.
CRITICAL CARE MEDICINE FACULTY
BRONCHOSCOPY PROCEDURE NOTE
Date:
Procedure: Bronchoscopy
Consent:
Indication: airway surveillance, secretion clearance
Monitoring: EKG, blood pressure, pulse oximetry
Anesthesia:
Physician:
Equipment: Ambu aScope
Complications: none
Entry: A bronchoscope was lubricated and introduced through the indwelling
Specimens:
Findings:
– Larynx: unable to assess (intubated)
– Tube: clean without bioburden
– Trachea: no secretions
– R mainstem: no secretions
– RUL: no secretions
– RML: no secretions
– RLL: no secretions
– L mainstem: no secretions
– LUL: no secretions
– LLL: no secretions
– Lingula: no secretions
—
Signature
