Post-Op

This is the note done as soon as the patient leaves the OR and is in PACU. This is supposed to be a brief summary in order for the nurses and rest of the team can see what recently took place. Sort of like a checkpoint status. A much longer version of this is dictated later when the time is allowed called a “Dictation” or “Operation Report Detail”

SAPPPA HEMI

BRIEF POST-OP NOTE

Surgeon:
Assistant:
Pre operative diagnosis:
Post operative diagnosis:
Procedure performed:
Anesthesia: Local block with 12cc of 0.5% marcaine plain and 10cc 1% lidocaine
plain with MAC

Hemostasis: Pneumatic ankle tourniquet at 250mmHg, electrocauterization, apply pressure
Estimated blood loss: 10cc. a full LAP is 100cc
Materials: 3-0 Nylon, 4-0 Monocril, 4-0 Nylon
IV fluids: 25cc LR
Implants : none
Specimens: none
Complications: none

Comments:

Patient tolerated procedure and anesthesia well and transferred to PACU with all
vital signs stable and reactive hyperemia to all digits