Date: 01/11/2024
Theatre episode: Kensington Hospital
Surgeon: Dr. Emily Carter
Anaesthetist: Dr. David Lee
Assistant: Dr. Sarah Jones
Procedure: Open reduction and internal fixation of a fractured left femur.
Prosthesis: Synthes intramedullary nail.
Informed consent details including confirmation that patient consented to procedure and discussion of risks/benefits: The patient was informed of the risks and benefits of the procedure, including the risks of infection, bleeding, nerve damage, and non-union. The patient confirmed understanding and provided consent.
Patient’s relevant recent medical history and findings that relate to surgical indication: The patient sustained a closed fracture of the left femur following a fall. X-rays confirmed a displaced mid-shaft fracture. The patient is otherwise healthy.
Discussion of conservative versus surgical management if such discussion occurred: The patient was informed that conservative management with traction and casting was an option, but surgical management was recommended due to the nature of the fracture and the patient's activity level.
Anaesthesia details including type and agents used: General anaesthesia was administered with sevoflurane and fentanyl.
Medications administered intraoperatively including analgesia, sedation, antiemetics or others: Fentanyl, ondansetron, and cefazolin were administered.
Details of urinary catheter insertion if performed: A Foley catheter was inserted prior to the procedure.
Details on how the patient was positioned for the procedure, including supports or padding used: The patient was positioned supine on a radiolucent table with a bump under the left hip.
Description of sterile skin preparation and draping technique: The left lower extremity was prepped with chlorhexidine and draped in a sterile fashion.
Timeout procedure details including confirmation of patient identity, procedure, and site: A timeout was performed confirming the patient's identity, the procedure (left femur ORIF), and the correct surgical site.
Antibiotics used intraoperatively, typically "Kefzol" or "Cephazolin", unless otherwise specified: Cephazolin 2g IV was administered.
Details of patient setup or positioning adjustments during the case: The patient was positioned supine on a fracture table.
Approach details including incision location and exposure technique: A lateral incision was made over the femur. The fracture site was exposed through blunt dissection.
Local infiltration details, including agents used and anatomical sites infiltrated: Local infiltration with 0.5% bupivacaine was performed.
Detailed step-by-step description of the procedure performed: The fracture was reduced and stabilized with an intramedullary nail. The nail was inserted antegrade. The fracture was reduced and the nail was locked proximally and distally.
Detailed description of intraoperative findings: The fracture was a comminuted mid-shaft fracture. The reduction was anatomical.
Standard closure steps and layers closed: The fascia was closed with vicryl. The subcutaneous tissue was closed with vicryl. The skin was closed with staples.
Details of wound closure including suture materials such as "vicryl" or "stratafix": The fascia was closed with 0 vicryl. The subcutaneous tissue was closed with 2-0 vicryl. The skin was closed with staples.
Details of dressings applied, typically including "cuticerin", "skin glue", "allevyn", or "mepilex": A sterile dressing was applied.
Plan:
Antibiotic continuation plan including type, route, and duration if mentioned: Cephazolin was continued for 24 hours postoperatively.
Anticoagulant plan if prescribed postoperatively: Enoxaparin 40mg subcutaneously daily was prescribed.
Mobilisation plan including weight-bearing status or use of mobility aids: The patient was instructed to be non-weight bearing on the left leg for 6 weeks. A walker was provided.
Follow-up with GP for wound review and check: The patient was advised to follow up with their GP for wound review in 10 days.
Follow-up plan with surgeon including timeframe, purpose, and setting of review: The patient was scheduled for a follow-up appointment in 2 weeks for wound check and X-rays.
Date: [insert date of dictation in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as single line.)
Theatre episode: [hospital name, either "Kensington Hospital" or "Southern Cross Northland"] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as single line.)
Surgeon: [full name of surgeon]
Anaesthetist: [full name of anaesthetist. Otherwise, write "Local anaesthetic only" if no anaesthetist involved] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as single line.)
Assistant: [full name of assistant] (Only include if explicitly mentioned in transcript or context, else omit section entirely. If no assistant is mentioned, omit this line entirely.)
Procedure: [details of surgical procedure performed] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as single line.)
Prosthesis: [details of prosthesis or instrumentation used] (Only include if explicitly mentioned in transcript or context, else omit section entirely. If not applicable, remove this heading and line.)
[Informed consent details including confirmation that patient consented to procedure and discussion of risks/benefits] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Patient’s relevant recent medical history and findings that relate to surgical indication] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Discussion of conservative versus surgical management if such discussion occurred] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Anaesthesia details including type and agents used] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Medications administered intraoperatively including analgesia, sedation, antiemetics or others] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Details of urinary catheter insertion if performed] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Details on how the patient was positioned for the procedure, including supports or padding used] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Description of sterile skin preparation and draping technique] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Timeout procedure details including confirmation of patient identity, procedure, and site] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Antibiotics used intraoperatively, typically "Kefzol" or "Cephazolin", unless otherwise specified] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Details of patient setup or positioning adjustments during the case] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Approach details including incision location and exposure technique] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Local infiltration details, including agents used and anatomical sites infiltrated] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Detailed step-by-step description of the procedure performed] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Detailed description of intraoperative findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Standard closure steps and layers closed] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Details of wound closure including suture materials such as "vicryl" or "stratafix"] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Details of dressings applied, typically including "cuticerin", "skin glue", "allevyn", or "mepilex"] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Plan:
[Antibiotic continuation plan including type, route, and duration if mentioned] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Anticoagulant plan if prescribed postoperatively] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Mobilisation plan including weight-bearing status or use of mobility aids] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Follow-up with GP for wound review and check] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Follow-up plan with surgeon including timeframe, purpose, and setting of review] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
(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 section blank. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
