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: <insert date>
Procedure: Bronchoscopy
Consent: <obtained, emergent>
Indication: airway surveillance, secretion clearance
Monitoring: EKG, blood pressure, pulse oximetry
Anesthesia: <IV sedation, topicalization, none>
Physician: <insert name>
Equipment: Ambu aScope <slim, regular, large>
Complications: none
Entry: A bronchoscope was lubricated and introduced through the indwelling <ETT, tracheostomy tube> in the standard fashion.
Specimens: <none, BAL>
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
