Maxillofacial Surgeon Template

Maxillofacial Surgery Operative Notes

A professional Maxillofacial Surgeon template for healthcare professionals.

About this template

Streamline your surgical documentation with our Maxillofacial Surgery Operative Notes template. Ideal for maxillofacial surgeons, oral and maxillofacial surgery residents, and surgical assistants, this template ensures comprehensive and accurate recording of operative details. From procedure specifics and ICD-10 codes to surgical team members, anaesthesia, and detailed intraoperative findings, every critical aspect of the surgery is covered. Designed for use with Heidi, this template intelligently populates sections based on your dictation, ensuring consistent, high-quality clinical notes that meet regulatory standards. Simplify your workflow and maintain meticulous records effortlessly with this essential tool for any maxillofacial practice.

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Operative Note – Maxillofacial Surgery Date: 1 November 2024 Location / Service Center: Cintocare Procedure Performed: - Open reduction and internal fixation of left mandibular angle fracture ICD-10 code: - S02.61XA Surgical Team: - Primary Surgeon: Dr. Thomas Kelly - Assistant: Dr. Sarah Jenkins Anaesthesia and Positioning: - General anaesthesia - Orotracheal intubation - 2% Lidocaine with 1:100,000 Epinephrine, 3.6 ml Surgical Approach and Technique: - A standard submandibular incision was made on the left side, approximately 2 cm inferior to the mandibular border. Dissection was carried through subcutaneous tissue and platysma. The facial artery and vein were identified and ligated. The fracture site at the left mandibular angle was exposed. Reduction was achieved using arch bars and intermaxillary fixation. A 2.0 mm titanium miniplate with four screws was applied to the inferior border of the mandible, followed by a second 2.0 mm miniplate superiorly. Final occlusion was verified. Wound closure was performed in layers. Findings and Intraoperative Observations: - Displaced, comminuted fracture of the left mandibular angle. No significant neurovascular injury observed intraoperatively. Adequate reduction and stable fixation achieved. Specimens and Devices: - Two 2.0 mm titanium miniplates with eight titanium screws (four per plate). Postoperative Instructions: - Follow-up appointment scheduled for 2 weeks post-op with Dr. Thomas Kelly for suture removal and clinical assessment. - Medications: Amoxicillin 500mg TDS for 7 days, Ibuprofen 400mg TDS PRN for pain, Chlorhexidine mouthwash BID for 14 days.

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.)

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