Maxillofacial Surgery Operative Notes

Operative Note – Maxillofacial Surgery Date: [Insert date note is made] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Location / Service Center: [Insert location/service center (e.g. Netcare Unitas; Life Groenkloof; CureDay Erasmuskloof; Centurion Day Hospital; Cintocare)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Procedure Performed: - [Describe each surgical procedure performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ICD-10 code: - [Insert ICD-10 code(s) explicitly documented in the transcript, contextual notes or clinical note] (Only include if explicitly mentioned; otherwise omit completely. Do not infer or generate codes.) Surgical Team: - Primary Surgeon: [Insert full name of primary surgeon] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Assistant: [Insert full name of assistant surgeon] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Anaesthesia and Positioning: - [Insert type of anaesthesia administered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Insert method of intubation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Insert local anaesthetic agents used, including concentration and volume] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Surgical Approach and Technique: - [Describe surgical approach and techniques used for each procedure] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Findings and Intraoperative Observations: - [Describe significant intraoperative findings and observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Specimens and Devices: - [Detail specimens collected and devices/materials used, including types and quantities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Postoperative Instructions: - [Insert referrals for follow-up care or additional procedures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Insert take-to-office medications or written postoperative instructions provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the section entirely. Never come up with your own patient details, diagnoses, ICD-10 codes, procedures, findings, or plans. Use only the transcript, contextual notes or clinical note as the source of truth. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing—simply omit the placeholder or section entirely. Never hallucinate.)