Office Procedure Note (Primary Care)

Last updated: Nov 2025

Office Procedure Note (Primary Care) that’s HIPAA-compliant: capture the procedure or upload audio, generate a structured note (indication → consent → steps → findings → post-care), then auto-fill your EHR via the Nudge Chrome extension (edit-before-save).

Who this helps

• Family medicine & internal medicine clinicians performing in-clinic procedures

• APPs (NPs/PAs) standardizing procedure documentation

• Clinic managers ensuring consent, safety checks, and discharge instructions are complete
  
  

What you get

• Structured Indication/Diagnosis, Consent, Procedure (site/prep/anesthesia/technique), Findings/Specimen, Complications, Post-Procedure Care/Plan, Disposition

• Optional fields for lot #, device, time-out checklist, photographs, and patient education

• Team-wide formatting controls (bullets/paragraphs) + redaction
  
  

How it works with your EHR

1. Capture or upload in Nudge → draft appears.

2. Review and confirm required safety/consent items.

3. In your EHR, open a new note and launch the Nudge extension.

4. Select patient + Procedure Note → confirm mapping (Indication, Consent, Procedure, Findings, Complications, Post-care, Disposition) → save & sign.
   No IT project required.
   
   

How to write an Office Procedure note

• Indication / Diagnosis: why you’re doing it; relevant findings.

• Consent: risks/benefits/alternatives; verbal/written; patient understanding.

• Procedure: site, prep, anesthesia (dose), technique, instruments, duration.

• Findings / Specimen: description; where the specimen went (e.g., formalin/path).

• Complications: none vs specify.

• Post-Procedure Care / Plan: dressing, meds, activity limits, return precautions, follow-up plan.

• Disposition: tolerated well; condition on discharge.
  
  

Quick examples

• Skin lesion excision or shave biopsy with path submission and wound care.

• I&D of abscess with culture and return precautions.

• Large joint injection with med lots and immediate response documented.

• Simple laceration repair with suture type, count, and removal date.
  
  

Full Sample Note — Office Procedure (Primary Care)

Example only; not medical advice.

Patient: Robert H., 56M
Procedure: Shave biopsy, left forearm lesion

HPI / SUBJECTIVE:
Robert is a 56-year-old man presenting for evaluation of a pigmented lesion on his left forearm. The lesion has been present for several months but recently changed color, prompting concern. He denies associated pain, bleeding, or ulceration. Past history is notable for hypertension and hyperlipidemia. No prior skin cancers.

PMH: Hypertension, Hyperlipidemia
PSH: None

Meds:

• Lisinopril 20 mg daily

• Atorvastatin 40 mg nightly

Allergies: NKDA

OBJECTIVE:

PHYSICAL EXAM (focused):
Vitals: Stable
Skin: 0.7 cm pigmented lesion, left forearm, asymmetric with irregular pigmentation
Other systems: Unremarkable

DIAGNOSTICS:
None obtained today.
Specimen sent for pathology.

PROCEDURE:
Indication: suspicious skin lesion
Consent was obtained from the patient. The lesion site was prepped with alcohol and anesthetized with 1% lidocaine with epinephrine. A shave biopsy was performed using a dermablade, and the specimen was placed in formalin for pathology. Hemostasis achieved with aluminum chloride. Dressing applied.
Post-procedure: Patient tolerated procedure well without complication. Wound care instructions provided.

ASSESSMENT & PLAN:
Robert is a 56-year-old man with hypertension and hyperlipidemia, presenting for shave biopsy of a suspicious skin lesion. Biopsy was completed successfully today and specimen submitted for histopathology. Differential includes benign nevus, dysplastic nevus, melanoma; management will depend on results

1. SUSPICIOUS SKIN LESION – LEFT FOREARM

• Shave biopsy performed, specimen to pathology

• Reviewed wound care and infection precautions

• Will contact patient with pathology results

2. HYPERTENSION

• Slightly elevated today at 142/86

• Continue lisinopril 20 mg daily

• Asked to keep home BP log for review at next visit

3. HYPERLIPIDEMIA

• On atorvastatin 40 mg nightly

• Last LDL 94 (6 months ago), within acceptable range

• Continue current regimen

FOLLOW UP:
Will call with pathology results. In office follow-up in 2–3 weeks for wound check or sooner if concerns arise.

DIAGNOSES:

• D48.5 — Neoplasm of uncertain behavior of skin of trunk and limbs (pending pathology)

• I10 — Essential (primary) hypertension

• E78.5 — Hyperlipidemia, unspecified
  
  

Results (2025)

Procedure notes finalized in < 60–90 seconds after capture.
Teams report 4–6 hrs/week saved and fewer missed consent or discharge elements.

FAQs

Can I enforce a time-out and consent checklist?
Yes. Mark safety items as required and block export until completed.

Can I include lot numbers, device IDs, or photos?
Yes. Optional metadata fields and image attachments can be captured and referenced.

How do I route pathology and follow-up?
Record where the specimen is sent and auto-generate a task to call the patient and schedule the wound check.