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.
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.
| 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 |
Tool: fhir_read
resourceType: "Patient"