Vasectomy Procedure Note Template - Reproductive Health Access Project printable pdf download

Vasectomy Procedure Note Template - Reproductive Health Access Project

Vasectomy Procedure Note

SUBJECTIVE

_____________________ is a _________ year old male who is coming today for a no scalpel vasectomy. He is

accompanied by his _____________. Informed consent is verified, to be signed and scanned into the chart, and

all additional questions answered. The details of the procedure are reviewed with the patient.

OBJECTIVE:

Vital signs: _______

Genitals normal; both testes normal without tenderness, masses, hydroceles, varicoceles, erythema or swelling.

Shaft normal, meatus normal without discharge. No inguinal hernia noted. No inguinal lymphadenopathy.

! Circumcised

! Uncircumcised

Procedure Note:

Time out taken:

Team: _______________________________, MD and _______________________.

Name and DOB of patient confirmed

! Yes

! No

Procedure: No Scalpel Vasectomy

Confirmed by patient and team

! Yes

! No

Position correct for procedure

! Yes

! No

Equipment for procedure available

! Yes

! No

Procedure note:

Under sterile conditions, lidocaine without epinephrine, total 2cc, was administered to provide local skin

anesthesia and a regional vasal block bilaterally. Next, the no-scalpel vasectomy approach was used to fix and

expose the left vas under the midline scrotal raphe 1 cm below the base of the penis. The vas was

hemitransected and thermal cautery applied to a 1 cm length inside the lumen of the prostatic end of the cut vas

until blanching occurred. The vas was then completely transected and fascial interposition achieved with one

metal clip over the prostatic end, and the testicular end left open. The area was inspected thoroughly and good

hemostasis was noted before the vas was reduced back into the scrotum. The procedure was repeated on the

right vas. Estimated blood loss was <2cc. Skin was dressed with sterile gauze. Tape was applied to keep the

bandage on overnight, and a scrotal support placed. The patient tolerated the procedure well.

The

October 2013 /

Vasectomy Procedure Note Template - Reproductive Health Access Project