Sample Opnote – Venous Radiofrequency Ablation

[This is a sample procedure note and may not match the corresponding guide exactly: As with all procedures there will be slight variations based on body habitus, technique preference, laterality, etc. Treat this as a starting point for a template. The brackets {{ }} are used in the body as placeholders for dynamic variables.]

[Written for a GSV. An SSV procedure would note the different vein and a prone position. Full procedure technique and overview here.]


Procedure Date: 

Pre-op diagnosis:

I87.2 Venous insufficiency (chronic) (peripheral)

I87.323 Chronic venous htn w inflammation of bilateral low extremity

Post-op diagnosis: Same

Anesthesia: Conscious Sedation

Pre-Procedure Review: The initial consultation report has been reviewed and there are no significant changes with regard to the patient’s medical, social history and review of systems. My findings on physical examination today are grossly consistent with those documented on the previous note, indicating the diagnoses above causing impairment in daily activities.The patient reports compliance with conservative care including leg elevation, exercise, analgesics, and stocking use but has inadequate response. I will proceed today with the scheduled procedure and see the patient back for follow-up. The patient states understanding of the risks and benefits, and is in agreement.

Procedure: Endovenous Ablation of the {{Left/Right}} Great Saphenous Vein




Consent was reviewed with the patient and all questions were answered.

The greater saphenous vein on the operative side was imaged with ultrasound from the distal calf to the saphenofemoral junction. The patient was placed on the table in supine position and the operative leg was prepped with chlorhexidine and draped in a sterile fashion.

The access site was anesthetized with 1 ml of 1% plain lidocaine. Access to the vein was obtained under ultrasound guidance with a 22 gauge micropuncture needle at the level of the mid-calf. This was exchanged for a 7Fr micro introducer over a 0.018in guidewire. The RF catheter was then advanced into the vein through the introducer, with the tip >1.5cm inferior to the superficial inferior epigastric vein and at least 2cm distal to the saphenofemoral junction.

The patient was placed in Trendelenburg position and tumescent anesthesia (0.05% lidocaine with epinephrine 1:100,000,000) was administered into the facial plane surrounding the vein with a 22 gauge needle. A total of {{volume}}cc tumescent solution was used. The vein was ablated with a 10cm heating element and then indexing the catheter forward in overlapping segments for each treatment for the length of the vein. The vein was treated to the proximal calf only.

External pressure was applied to the vein. Device temperature was maintained at 120±5℃ with an initial power level of 40W dropping to below 20W for each treatment. The total length of the vein treated was {{treatment length}} cm. EBL was < 10cc. The patient was awake and able to answer questions during the actual ablation and denied any discomfort or paresthesia during the process.

Post procedure: The leg was then cleaned with water. A 4×4 dressing was applied over the access site. A graduated compression stocking was then applied.

The patient was ambulated normally in the office for 15 minutes. Postoperative instructions were reviewed and the patient verbalized understanding. Follow up arrangements were made. The patient tolerated the procedure well and was discharged home