Procedure note template
A procedure note has to stand on its own if anyone later asks what was done, why, and how the patient was left. This page gives a blank template for minor and office procedures, a completed invented punch biopsy note, the omissions that cause trouble, and how the ClearPass Procedure structure drafts it.
What a procedure note must answer
- Why: the indication, and the diagnosis before the procedure.
- Agreement: that risks, benefits and alternatives were discussed and the patient consented, in the form your service requires.
- Who and how: operator, assistant, site and side, positioning, preparation, anaesthesia with drug, strength and volume.
- What was done and found: technique in brief, findings, specimens sent and where.
- How it ended: estimated blood loss where relevant, complications or none, closure, dressing, the patient's condition afterwards.
- What happens next: aftercare advice, warning signs, suture removal or review, and how results will be communicated.
Blank procedure template
PROCEDURE NOTE Procedure: Date and time: Operator: [ ] Assistant: [ ] Indication / pre-procedure diagnosis: Consent: risks, benefits, alternatives discussed; consent obtained [verbal / written] Site and side confirmed: [ ] Preparation and positioning: Anaesthesia: [agent, strength, volume] Technique: Findings: Specimens: [type, sent to] Blood loss: Complications: [none / describe] Closure and dressing: Condition after procedure: Aftercare advice given: Follow-up: [suture removal / results / review]
Filled example: punch biopsy
Procedure: 4 mm punch biopsy, skin of left upper back. Indication: 9 mm irregular pink scaly plaque present 4 months, not responding to 4 weeks of topical steroid; differential includes superficial basal cell carcinoma and eczema. Consent: bleeding, infection, scarring and a possibly non-diagnostic result discussed; alternatives including excision and observation discussed. Verbal consent obtained and documented per clinic policy. Site confirmed with patient using mirror and photograph on file. Preparation: skin cleaned with chlorhexidine. Patient prone. Anaesthesia: lidocaine 1% with adrenaline, 2 mL, local infiltration. Technique: 4 mm punch at the edge of the plaque, including lesional and adjacent skin. Specimen lifted and cut at base. Specimen: sent to histopathology in formalin. Blood loss: minimal. Complications: none. Closure: one 4-0 nylon interrupted suture. Dry dressing. Condition: comfortable, no bleeding at 10 minutes. Aftercare: keep dry 24 hours, then gentle washing; paracetamol if sore. Return if spreading redness, pus or fever. Follow-up: suture removal in 10-14 days; results discussed by phone when available.
Omissions that cause problems
- Side and site not stated, or stated only as back without a landmark.
- Local anaesthetic volume and strength missing, which matters if a second procedure follows the same day.
- Complications left blank instead of written as none.
- Specimen sent but no note of who will chase the result and how the patient will hear it.
- Consent described as obtained, without the risks that were actually discussed.
How the ClearPass Procedure structure works
The Procedure structure writes indication, what was done, findings, complications and aftercare. It adds nothing that was not said. That is the right rule for a procedure note, and it means the note is only as complete as what you say aloud or type. Many clinicians narrate the key facts during or right after the procedure: the site and side, the drug and volume, specimen sent, complications none. Say those lines and they will appear.
Tap Transcribe once the patient has agreed, and Stop when you are done; the draft appears in English. If your service has a fixed procedure form, such as the one above with operator and consent lines, save those headings under My own structure and reuse them for every procedure. As with every ClearPass note, the draft is reviewed and corrected by you before it goes into the chart, and procedure (CPT) codes can be suggested where your country uses them. For dermatology-heavy clinics see the AI scribe for dermatology page.
What ClearPass does not do
- It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
- It is not a medical device and does not make clinical decisions. It is a documentation aid.
- It does not connect to your EMR. The note is copy-ready text that pastes into any system.
Privacy
Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.
Questions
Does a procedure note need a separate consent form?
That depends on the procedure and your service's policy. The note should still state what was discussed and how consent was given.
Can ClearPass fill in the lidocaine dose if I forget to say it?
No. It does not add details that were not said or typed. The line stays empty so you notice and fill it.
Is the Procedure structure only for surgery?
No. It suits any procedure note: joint injections, biopsies, suturing, endoscopy summaries, or line insertions, as long as the details are said or typed.
What does ClearPass cost?
The 7-day trial is free, needs no card and simply ends after 7 days, with no automatic charge. After that there is one plan: $78 a month or $858 a year, with every visit transcribed.
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