Dictation Sample

Name: Joe Sample
Record #: 2813308004

Pre-Op Diagnosis:
Post-Op Diagnosis:

Surgeon: Dr. Mallet DPM


Before surgery
“The patient was brought into the OR suite and placed in the(supine, prone, lateral) position. (MAC, general, spinal) anesthesia was appropriately induced. A pneumatic (ankle/thigh) tourniquet was placed on the (left/right) extremity . Our attention was then directed to the (left/right) site which we noted a (skin tenting, abscess, bunion, deformity, fracture, etc.). Using 20cc of 1:1 mixture of 1% Lidocaine plain and 0.5% Marcaine plain, we performed a (Common Peroneal/ PT) block in the (MAYO, Ankle block) fashion. The foot was scrubbed, prepped, and draped in an aseptic manner. An Esmarch bandage was used to exsanguinate the (left/right) foot. The (ankle/thigh) tourniquet was inflated and set to ________mmHg.”

During Surgery
“At this time, attention was directed to the dorsal aspect of the first metatarsal head of the (left/right) foot where a 5cm linear longitudinal incision was made medial to the EHL, following the contour of the deformity. The incision was deepened using blunt dissection. All vital neural and vascular structures were identified. All bleeders were cauterized with Bovie as necessary… ”

After Surgery
“The tourniquet was deflated and it was noted a hyperemic response of the (left/right) lower extremity. A postoperative block consisted of ____cc’s of 0.5% Marcaine plain. The incision site was then dressed with___________(Betadine soaked adaptic, Xeroform, gauze, Kling, Kerlix, steri-strips). A posterior splint, post-op shoe, CAM boot were then applied.”

“The patient will be discharged home with written instructions.”