Surgeon Template

Operative Note – Standard Surgical Procedure

A professional Surgeon template for healthcare professionals.

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Streamline your surgical documentation with Heidi's Operative Note – Standard Surgical Procedure template. This essential tool for surgeons and surgical residents meticulously captures all critical details of an operation, from the initial indication and anatomical site to precise surgical steps and post-operative plans. It's perfectly suited for diverse surgical specialties, including general surgery, orthopaedics, and gynaecology, especially within a South African clinical context, noting interventions related to common regional health challenges. Heidi intelligently populates sections on patient positioning, intraoperative findings, and any complications, ensuring a comprehensive and accurate record. Enhance efficiency and compliance with a structured template designed for clarity and ease of use in any hospital setting.

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Operative Note – Standard Surgical Procedure Procedure Name and Indication: Laparoscopic Cholecystectomy for symptomatic cholelithiasis. The patient presented with recurrent episodes of right upper quadrant pain, nausea, and occasional vomiting, consistent with biliary colic. Ultrasound imaging confirmed multiple gallstones and a thickened gallbladder wall. This procedure was performed in a regional hospital setting. Date, Team, and Anaesthesia: 01/11/2024. Primary Surgeon: Dr. Sarah Davies. Assistant Surgeon: Dr. Emily White. Anaesthetist: Dr. James Brown. Type of anaesthesia: General anaesthesia. Performed in a regional hospital. Patient Positioning and Site Preparation: Patient was placed in the supine position. Abdomen was prepped with chlorhexidine solution. The surgical site was marked pre-operatively as per local theatre protocol, specifically in the right upper quadrant. Surgical Steps and Intraoperative Details: Standard four-port laparoscopic technique was employed. A 10mm umbilical port was used for the camera. Two 5mm working ports were placed in the right upper quadrant and one 5mm port in the epigastrium. Calot's triangle was meticulously dissected, and the cystic duct and cystic artery were identified, clipped using titanium clips, and divided. The gallbladder was then dissected from the liver bed using electrocautery. Minimal bleeding encountered. A standard laparoscopic cholecystectomy surgical kit was utilised. No specialised equipment was required. Findings and Key Observations: The gallbladder was distended and inflamed with a thickened wall, consistent with chronic cholecystitis. Multiple cholesterol stones, the largest measuring approximately 1.5 cm, were present within the lumen. No evidence of common bile duct dilatation or stones. Liver appeared unremarkable. Complications and Intraoperative Management: No intraoperative complications such as bleeding, injury to bowel, bladder, or major vessels were observed. Anaesthetic course was stable throughout the procedure. No conversion to open surgery was necessary. Closure and Postoperative Plan: Gallbladder was extracted through the umbilical port using an endo-bag. Fascial defects at the 10mm port site were closed with Vicryl sutures. Skin incisions were closed with subcuticular Vicryl and Steri-Strips. Dressings applied. Post-operative care instructions include routine analgesia (paracetamol and ibuprofen), oral antibiotics (Amoxicillin/Clavulanate for 5 days), and early mobilisation. Patient was transferred to the general ward in stable condition. Post-operative review arranged for 24 hours post-surgery.

Operative Note – Standard Surgical Procedure Procedure Name and Indication: [document the official name of the procedure performed, including indication and anatomical site. Include clinical context relevant to the South African setting, such as surgery for complications of TB, trauma, malignancy, or obstetric emergencies] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Date, Team, and Anaesthesia: [include the date of operation in DD/MM/YYYY format, names of primary and assistant surgeons, anaesthetist, and type of anaesthesia (e.g. general, spinal, regional block). Mention if performed in a district, regional, or tertiary hospital setting] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Patient Positioning and Site Preparation: [describe patient positioning (e.g. supine, lateral, lithotomy), antiseptic prep (e.g. chlorhexidine, iodine), and whether site was marked pre-operatively as per local theatre protocol] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Surgical Steps and Intraoperative Details: [provide sequence of steps taken during the procedure, instruments or implants used, anatomical structures encountered, and any deviation from standard technique. Include use of surgical kits commonly available in state hospitals or if any specialised equipment was required in the private sector] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Findings and Key Observations: [note any abnormal or unexpected anatomical/pathological findings, such as abscesses, adhesions, perforation, tumour spread, necrosis, or anatomical variants encountered during the procedure] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Complications and Intraoperative Management: [include any intraoperative complications such as bleeding, injury to bowel, bladder, or major vessels, anaesthetic complications, or need for conversion/escalation. Document intraoperative actions taken to manage complications] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Closure and Postoperative Plan: [detail method of wound closure (e.g. interrupted sutures with nylon, subcuticular Vicryl), placement of drains, dressings applied, and post-op care instructions including analgesia, antibiotics, early mobilisation, or ward transfer. Note if the patient was transferred to ICU or general ward, and if post-op review was arranged] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs, or bullet points as needed to capture all the relevant information from the transcript.)

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