Neurosurgeon Template
Theatre Notes
A professional Neurosurgeon template for healthcare professionals.
About this template
Streamline your neurosurgical theatre documentation with our dedicated "Theatre Notes" template. Perfect for busy neurosurgeons and their teams, this template ensures every critical detail of a craniotomy, spinal fusion, or other complex neurological procedure is meticulously captured. From patient demographics and precise surgical steps to instrumentation, complications, and postoperative instructions, this template simplifies compliance and enhances patient care records. Clinicians can effortlessly log diagnoses (including ICD-10 codes), anaesthesiology details, and estimated blood loss. With Heidi, this template intelligently populates fields directly from your consultation, ensuring accuracy and saving valuable time, making it an indispensable tool for efficient medical practice.
Preview template
Date of surgery: 01/11/2024
File Number: NS-2024-00123
Patient Name: Sarah Jane Smith
Date of birth: 15/05/1978
Age: 46
Patient's weight: 70 kg
Patient's height: 165 cm
Patient's BMI: 25.7 kg/m²
Surgeon: Dr. Eleanor Vance
Additional surgeon: Dr. Marcus Thorne
Assistant: Nurse Rachel Green
Anaesthesiologist: Dr. Alan Peterson
Diagnosis: Brain tumour, unspecified (C71.9)
Procedure: Craniotomy for tumour resection
Rule J Motivation:
1. Patient experiencing progressive neurological deficits including hemiparesis and speech difficulties.
2. Imaging reveals rapidly growing lesion causing significant mass effect.
3. Conservative management has failed to halt symptom progression.
Instrumentation: High-speed drill, CUSA Excel+ Ultrasonic Surgical Aspirator, various micro-dissectors, bipolar cautery, Mayfield head clamp.
Prophylactic antibiotics: Cefazolin 2g IV
Start time: 08:30 AM
End time: 01:45 PM
Duration of surgery: 315 minutes
Estimated blood loss: 350 ml
Cell Saver: 150 ml reinfused
Procedural steps:
1. Patient positioned supine with head in Mayfield clamp, secured and prepped.
2. curvilinear incision made in the right temporoparietal region.
3. Craniotomy performed with high-speed drill and bone flap elevated.
4. Dura incised in a cruciate fashion, reflected.
5. Intraoperative neuronavigation used to locate tumour boundaries.
6. Tumour identified and debulked using CUSA, followed by micro-dissection and bipolar cautery to achieve gross total resection.
7. Haemostasis secured.
8. Dura closed with 4-0 Nurolon sutures.
9. Bone flap replaced and secured with titanium plates and screws.
10. Muscle and fascia closed in layers, skin closed with staples.
Complications: None reported intraoperatively.
Postoperatively: Patient extubated in theatre, responsive to commands. Transferred to Neurosurgical Intensive Care Unit (NICU) for close monitoring. Postoperative CT scan ordered to assess for any residual tumour or complications. Instructions include hourly neurological observations, strict fluid balance, and pain management with PCA.
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