Surgical Report.
Date of Report: 1 November 2024
Patient Name: John Smith
Date of Birth: 12/03/1960
Medical Record Number: 1234567
Surgeon: Dr. Emily Carter
Assistant(s): Dr. David Lee, Dr. Sarah Jones
Anesthesiologist: Dr. Michael Brown
Date of Surgery: 30 October 2024
Time of Surgery: 09:00 - 12:00
Procedure Performed: Laparoscopic Cholecystectomy
Indications for Surgery: Symptomatic gallstones, recurrent biliary colic.
Anesthesia: General anesthesia
Estimated Blood Loss: 100 mL
Fluids: 1500 mL Lactated Ringer's solution
Drains: None
Specimens: Gallbladder sent for pathology
Complications: None
Findings: Gallstones present in gallbladder. No evidence of choledocholithiasis.
Description of Procedure: The patient was placed in a supine position. A 1 cm incision was made at the umbilicus, and a pneumoperitoneum was established. Three additional trocars were placed. The gallbladder was dissected free from the liver bed. The cystic duct and artery were clipped and divided. The gallbladder was removed. The abdomen was inspected for bleeding. The trocars were removed, and the incisions were closed.
Postoperative Plan: Patient to be monitored in the recovery room. Pain management with IV analgesics. Diet as tolerated. Discharge home with oral pain medication and follow-up appointment in two weeks.
Condition on Discharge from OR: Stable, awake, and breathing spontaneously.
Surgical Report.
Date of Report: [date of report creation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Patient Name: [patient's full name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Date of Birth: [patient's date of birth] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medical Record Number: [patient's unique medical record number] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Surgeon: [name of operating surgeon] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Assistant(s): [names of surgical assistants] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Anesthesiologist: [name of anesthesiologist] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Date of Surgery: [date when the surgery was performed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Time of Surgery: [start and end times of the surgical procedure] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Procedure Performed: [detailed description of the surgical procedure carried out] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Indications for Surgery: [reasons and medical justification for performing the surgery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Anesthesia: [type and method of anesthesia used during the procedure] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Estimated Blood Loss: [estimated volume of blood lost during the surgery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Fluids: [types and amounts of intravenous fluids administered during surgery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Drains: [type, location, and status of any drains placed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Specimens: [description of any tissues or fluids removed and sent for pathology] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Complications: [any adverse events or difficulties encountered during the surgery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Findings: [description of significant intraoperative observations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Description of Procedure: [step-by-step narrative of the surgical technique, including incisions, dissections, repairs, and closures] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Postoperative Plan: [instructions for immediate postoperative care, including monitoring, medications, and activity restrictions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Condition on Discharge from OR: [patient's status upon leaving the operating room] (Only include if explicitly mentioned in transcript, context or clinical note, 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, depending on the format, as needed to capture all the relevant information from the transcript.)
