Medical operative note samples:
OPERATIVE NOTE SAMPLE #1
| DATE OF SURGERY: | 09/05/10 |
| PREOPERATIVE DIAGNOSIS: | Cataract and glaucoma of the left eye. |
| POSTOPERATIVE DIAGNOSIS: | Cataract and glaucoma of the left eye. |
| OPERATIVE PROCEDURE: | Combined phacoemulsification of cataract extraction with primary trabeculectomy without mitomycin of the left eye. |
| SURGEON: | Harry Richard, M.D. |
| ANESTHESIA: | Retrobulbar block and monitored anesthesia care. |
| SPECIMEN: | Lens nuclear material. |
| ESTIMATED BLOOD LOSS: | Minimal. |
| COMPLICATIONS: | None. |
INDICATIONS FOR PROCEDURE: This is a 78-year-old Hispanic female with a diagnosis of cataract and glaucoma affecting her activities of daily living. All the risks and benefits of the procedure were explained to the patient. She agreed to sign an informed consent.
PROCEDURE: The patient was taken to the Operating Room and was placed in a recumbent position. A time out was conducted in which the patient’s identity, surgical procedure, intraocular lens power, and name were verified by the surgeon, circulating nurse and scrub nurse. Attention was given to the right eye and using a lid speculum to open the eye lids. We used a lid speculum to open the iris of the right eye to initiate the procedure. Then using a 0.12 forceps and a 15º diamond blade, a paracentesis was performed on the temporal clear cornea. We injected nonpreserved lidocaine 1 cc through the paracentesis in order to anesthetize the anterior chamber. The anterior chamber was then refilled through the same incision with viscoelastic. Then we used a 2.75 diamond blade to perform a shelved temporal clear corneal incision. We refilled the anterior chamber with additional viscoelastic and then used cystotome and Utrata forceps to complete an anterior capsulotomy. Then we performed hydrodissection, hydrodelineation, phacoemulsification, irrigation and aspiration of the lens cortical material, and then we implanted an artificial intraocular lens implant power of +21.5 diopters Model SN60WF serial number 10002451 inside the capsular bag without any complications.
At the end of the procedure, we used irrigation and aspiration to remove the viscoelastic material, injected 1 cc of Miostat to constrict the pupil, and the seal the corneal wound with balanced salt solution. We then placed some antibiotic ointment on the eye. An eye patch and shield were also placed. We sent the patient to the Recovery Room without any complications where he received postoperative instructions and follow up appointments.
OPERATIVE NOTE SAMPLE #2
| DATE OF OPERATION: | 03/20/10 |
| PREOPERATIVE DIAGNOSIS: | Ptosis and dermachalasis of the upper lids. |
| POSTOPERATIVE DIAGNOSIS: | Ptosis and dermachalasis of the upper lids. |
| OPERATIVE PROCEDURE: |
Ptosis repair and blepharoplasty of the upper eye lids |
| SURGEON: | Harry Richard, M.D. |
| ANESTHESIA: | Local with monitored anesthesia care. |
| ESTIMATED BLOOD LOSS: | Less than 5 cc |
| COMPLICATIONS: | None. |
JUSTIFICATION OF THE PROCEDURE: The patient was complaining of progressive dropping of the upper lids with excess skin hanging down over the lashes. The skin was casting a shadow over the vision making it difficult to see. The visual field testing was performed which demonstrated a loss of the superior visual field in the primary position. By taping the excess skin up, there was a marked improvement in the visual field.
DESCRIPTION OF THE PROCEDURE: After informed consent was obtained, the patient was brought to the Operating Room. A lip crease was marked at 9-10 mm both the lid margin. Excess skin was outlined with a green forceps. A 50/50 mixture of Xylocaine 1.0% with epinephrine mixed with 0.75% Marcaine with epinephrine was then injected into the upper lids. The face was prepped and draped in the usual standard fashion. An incision was then made over the previously marked lines with a Colorado needle. A skin muscle flap was then excised with the Bovie cutting cautery. Hemostasis was achieved with a Bovie. The septum was then opened with the Bovie. Excess medial fat was excised with a hot cautery. A segment of levator aponeurosis was excised from the anterior border of the tarsus. The newly cut edge of aponeurosis was then advanced and hooked to the distal aponeurosis with three 6-0 Vicryl sutures. These were adjusted until appropriate lid height and contour were achieved. The sutures were then passed through the subcutaneous tissue of the inferior wound margin to recreate the lid crease. The skin was then closed with interrupted and a running 6-0 plain suture. The patient tolerated the procedure well and left the Operating Room in good condition.
OPERATIVE NOTE SAMPLE #3
| DATE OF OPERATION: | 03/20/10 |
| PREOPERATIVE DIAGNOSIS: | Ptosis and dermachalasis of the upper lids. |
| POSTOPERATIVE DIAGNOSIS: | Ptosis and dermachalasis of the upper lids. |
| OPERATIVE PROCEDURE: | Ptosis repair and blepharoplasty of the upper eye lids |
| SURGEON: | Harry Richard, M.D. |
| ANESTHESIA: | Local with monitored anesthesia care. |
| ESTIMATED BLOOD LOSS: | Less than 5 cc |
| COMPLICATIONS: | None. |
JUSTIFICATION OF THE PROCEDURE: The patient was complaining of progressive dropping of the upper lids with excess skin hanging down over the lashes. The skin was casting a shadow over the vision making it difficult to see. The visual field testing was performed which demonstrated a loss of the superior visual field in the primary position. By taping the excess skin up, there was a marked improvement in the visual field.
DESCRIPTION OF THE PROCEDURE: After informed consent was obtained, the patient was brought to the Operating Room. A lip crease was marked at 9-10 mm both the lid margin. Excess skin was outlined with a green forceps. A 50/50 mixture of Xylocaine 1.0% with epinephrine mixed with 0.75% Marcaine with epinephrine was then injected into the upper lids. The face was prepped and draped in the usual standard fashion. An incision was then made over the previously marked lines with a Colorado needle. A skin muscle flap was then excised with the Bovie cutting cautery. Hemostasis was achieved with a Bovie. The septum was then opened with the Bovie. Excess medial fat was excised with a hot cautery. A segment of levator aponeurosis was excised from the anterior border of the tarsus. The newly cut edge of aponeurosis was then advanced and hooked to the distal aponeurosis with three 6-0 Vicryl sutures. These were adjusted until appropriate lid height and contour were achieved. The sutures were then passed through the subcutaneous tissue of the inferior wound margin to recreate the lid crease. The skin was then closed with interrupted and a running 6-0 plain suture. The patient tolerated the procedure well and left the Operating Room in good condition.
OPERATIVE NOTE SAMPLE #4
| DATE OF OPERATION: | 09/05/12 |
| PREOPERATIVE DIAGNOSIS: |
Right hallux limitus, right foot. Superior DJD with osteophytic changes, right first MPJ |
| POSTOPERATIVE DIAGNOSIS: | Right hallux limitus, right foot. Superior DJD with osteophytic changes, right first MPJ |
| OPERATIVE PROCEDURE: |
Exostectomy of right first MPJ. Subchondral drilling of damaged articular surface, first MPJ right foot. |
| SURGEON: | Harry Richard, M.D. |
| ASSISTANT: | Jane Doe D.P.M |
| ANESTHESIA: | MAC with local. |
| HEMOSTASIS: | A pneumatic right ankle tourniquet set at 250 mmHg. |
| MATERIALS: | 3-0 Vicryl, 4-0 Vicryl, 4-0 nylon |
| ESTIMATED BLOOD LOSS: | Less than 10 cc |
JUSTIFICATION FOR PROCEDURE: This is a 52-year-old male who presented to the Medical Clinic and was treated by Dr. Brass for painful bony proliferation and limited joint range of motion of the patient’s right first MPJ. Upon clinical evaluation Dr. Richard took x-rays and reviewed the osteoarthritic changes and the osteophyte that was seen on the first metatarsal dorsally. It was reviewed with the patient the likelihood for conservative treatment to be unable to completely resolve his problem. The patient was to explore less conservative measures. Surgery was reviewed. The patient was explained that there would be a small bone cut, taking away the sharp bony proliferation and there would be an incision on the dorsal aspects of his foot. There would be minimal chance of decrease range of motion for anywhere from 2-4 months status post procedure. The patient understood all risks and benefits of the procedure and wished to continue with the procedure. Preoperative medical clearance was obtained from the patient PCP.
PROCEDURE IN DETAIL: Under mild sedation the patient was brought in the Operating Room, placed on the operating table in the supine position. Following induction of monitored anesthesia care, local anesthesia was obtained. The patient’s right first utilizing 16 cc of 1:1 mixture of 1.0% Xylocaine plain and 0.5% Marcaine plain. The patient’s foot was than scrubbed prepped and draped in usually aseptic fashion. Esmarch bandage was used to exsanguinate the patient’s right foot and the pneumaticankle tourniquet was set 250 mm Hg. A skin scriber was used to outline an incision over the first MPJ that was approximately 6 cm in length. It was over the central aspect just medial to extensor hallucis longus. A #15 blade was used to make an incision down the epidermis and dermis being careful not to violate the extensor hallucis longus. All bleeding structures that are encounter were ligated as deemed necessary. Sharp and blunt dissection was carried out to level of the capsular tissue. Immediately, there was noted to be a very firm presentation of the capsular tissue consistent with chronic synovitis. A #15 blade was used to make capsular and periosteal incision over the dorsal aspect of the first MPJ in which the medial collateral ligament was now explored. There was noted to be a large prominent osteophytic lipping of the dorsal aspect of the first MPJ. There was noted be an intraosseous joint mice/loose bodies attached to the dorsal aspect of the proximal phalanxes. There was noted to be degenerative changes to the dorsal one-third of the first MPJ articular surface. At this time, a #38 blade was used to resect the exostosis of the dorsal aspect of the first metatarsal. All rough edges that were seen in the medial dorsal and lateral aspect of the MPJ with a smooth utilizing power rasp. A rongeur was also used at this time, to debride any sharp osteophytic lipping of the base of the proximal phalanx. The wound was then flushed with copious balanced salt saline and the McClamary elevator was used to free up any plantar capsular adhesions. The first MPJ was brought through a range of motion. There was noted to be a drastic increase in range of motion. A 4/5 K-wire was used at this time to place approximately 8 holes, utilizing a 4/5 K-wire a.k.a. subchondral drilling into the dorsal one-third of the first metatarsophalangeal joint.
Next, the wound was then also flushed with copious amounts of normal saline. It was explored to make sure there were not any loose bony artifacts in the first MPJ. The capsule and periosteum was closed utilizing 3-0 Vicryl. Deep dermis was closed utilizing 4-0 Vicryl and the skin was closed utilizing 4-0 nylon. The patient’s foot was then scrubbed with a wet and dry Ray-Tec. Betadine soaked with Baciguent was the placed over the incision site. Then 4 x 4 Ace, Coban and Kling were placed around the patient’s right foot. The pneumatic ankle tourniquet was dropped at the time and there was noted to be a prompt hyperemic response to all digits of the right foot with adequate capsule time of digits 1-5. The patient was then transferred from Operating Room to PACU with all vitals sable and vascular status intact and all areas of the right foot. The patient received the following postoperative instructions. To remain partial weight bearing while wearing only postoperative shoe on the right heal. The patient will be given crutches if deem necessary. The patient is given a prescription with p.o. antibiotics and p.o. pain medication. The patient will follow-up with Dr. Richard in the postoperative Medical Clinic. The patient is instructed to keep the bandage clean, dry, and intact.
OPERATIVE NOTE SAMPLE #5
| DATE OF SURGERY: | 09/05/10 |
| PREOPERATIVE DIAGNOSIS: | Menometrorrhagia. |
| POSTOPERATIVE DIAGNOSIS: | Menometrorrhagia. |
| OPERATIVE PROCEDURE: | D&C. |
| SURGEON: | Harry Richard, M.D. |
| ASSISTANT: | Pamela Walker, D.P.M |
| ANESTHESIA: | General. |
DESCRIPTION OF OPERATION: The patient was placed on the operative table in the dorsal lithotomy position. Under general anesthesia, after prepping and draping in the usual sterile fashion, the bladder was emptied with a straight catheter. A bimanual pelvic examination revealed the patient had a normal exocervix, the uterus was enlarged about 10 cm. A wire speculum was placed in the posterior wall of the vagina. A tenaculum was grasped onto the lip of the cervix, after emptying the bladder with a straight catheter. The endometrial cavity was measured to 10 cm. We performed dilatation with Hegar #9. We then proceeded to explore the endometrial cavity obtaining a few fragments. Immediately after that, the endometrial cavity was explored with the curette #1 obtaining a sample of tissue. After being sure no excessive bleeding had occurred, we removed the tenaculum and speculum. We sent the patient to the Recovery Room in satisfactory condition.