Documentation Templates

Sacral decubitus ulcer debridement - lateral decubitus position - (OR) Author: Garrett Skinner Service: GS (white) Copy template

Sacral Ulcer Debridement Risks, benefits, alternatives discussed with the patient's HCP and informed consent was obtained. The patient was placed on the OR bed in supine position. General anesthesia was induced, and the patient was intubated without issue. The patient was positioned in the right lateral decubitus position. This was secured with a beanbag and all bony prominences padded. Straps were placed to secure the patient. Superficial wound cultures were taken. The wound was prepped with iodine and draped in a sterile fashion. Necrotic tissue was sharply debrided to the areas of healthy tissue around the wound using electrocautery. The deep tissue was debrided and there was no exposed bone. Debrided tissue was sent for culture and pathology. Hemostasis was achieved with topical lidocaine with epinephrine 10 cc and electrocautery. Wound measured [] ACell was placed throughout the entire wound bed covered with Xeroform and then sprayed with an additional local anesthetic and allowed to dry. Next bacitracin was placed and saturated with Xeroform. Dry Kerlix placed over this. ABD over this and secured with tape and finally Ioban was placed on top. The patient was replaced in the supine position liberated from anesthesia uneventfully and transferred to the PACU in stable condition.

Sacral decubitus ulcer debridement - bedside Author: Garrett Skinner Service: GS (white) Copy template

Risks and benefits of bedside debridement were discussed with the HCP and witness informed consent was obtained. The patient was placed on their side and prepped with iodine and draped in the normal sterile fashion. Necrotic tissue was debrided sharply with a scalpel and scissors. The wound measured []. And there was [bone?]. Hemostasis was achieved with pressure. The wound was dressed with wet-to-dry Kirlex, ABD and secured with paper tape. The patient tolerated the procedure well and wound care instructions entered into the chart.

Sacral decubitus ulcer debridement eqiupment Author: Garrett Skinner Service: GS (white) Copy template

Bucket Abd x5 4x4 gauze x 1box ?Laceration repair kit 10 cc syringe x1 Blunt needle x1 25g injection needle x1 chucks pad x1 bottle normal saline x1 sterile gloves x2 paper tape roll x1 Kirlex roll x3

Laparoscopic appendectomy - MM Author: Garrett Skinner Service: GS (white) Copy template

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position. [A foley was placed]. [abx] was given prior to the start of the procedure. The patient was secured to the table and all boney areas padded. The abdomen was prepped and draped in the normal sterile fashion. A timeout was done and all were in agreement. The abdomen was accessed via optical trocar in the left upper quadrant and insufflated. The area was inspected and there was no bleeding or visceral injury. A 12 mm infraumbilical trocar was placed and a 5 mm left lower quadrant trocar under direct visualization. The patient was placed in Trendenlenurg. The appendix was visualized in [area] and noted to be [perforated?]. The cecum was noted to be [appearance]. The appendix was grasped and retracted upwards. The mesoappendix was transected to the base using the Harmonic scalpel. The appendix was separated at its base using an EndoGia [color] staple load. The staple line was noted to be intact and hemostatic. The appendix was placed in a bag. The area was gently irrigated. The appendix was removed through the umbilical incision. The abdomen was desufflated and the umbilical fascia closed with 2-0 Vircyl using the Carter-Thomason device. The skin of all three incisions were closed with 4-0 Monocryl and dressed with Dermabond. The patient was liberated from anesthesia, extubated and transported to the PACU in stable condition. The attending surgeon was present throughout the entire procedure.

Laparoscopic cholecystectomy - MM Author: Garrett Skinner Service: GS (white) Copy template

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position. [A foley was placed]. [abx] was given prior to the start of the procedure. The patient was secured to the table and all boney areas padded. The abdomen was prepped and draped in the normal sterile fashion. A timeout was done and all were in agreement. The abdomen was accessed via optical trocar in the left upper quadrant and insufflated. The area was inspected and there was no bleeding or visceral injury. 11 mm supra umbilical, 5 mm right lateral, 5 mm right upper quadrant trocars were placed under direct visualization. The gallbladder was visualized and noted to be [appearance]. The gallbladder was retreated towards the patient’s right shoulder. Adheared stomach and fat were bluntly pushed away from the gallbladder. The hepatocystic triangle was dissected with blunt technique and hook cautery. The cystic duct and after were identified and skelatonized. The lower 1/3 of the gallbladder was dissected from the liver bed and the CVOS was achieved. The cystic duct and arteries were clipped in triplicate and transected with scissors. The gallbladder was separated from the cystic plate with hook cautery. It was placed in a bag. The clips were noted to be in place. The liver bed was noted to be hemostatic. The gallbladder was removed through the umbilical incision. The umbilical fascia was closed with 2-0 Vicryl and the Carter-Thomason device. An additional interrupted 2-0 Vircyl simple stitch was used. The abdomen was desufflated. The skin incisions were closed with 4-0 Monocryl and dressed with derma bond. The patient was liberated from anesthesia, extubated and transported to the PACU in stable condition. The attending surgeon was present throughout the entire procedure.

Laparoscopic appendectomy - CS Author: Garrett Skinner Service: GS (white) Copy template

Informed consent was obtained. Preoperative antibiotics were provided. The patient was brought into the operating room and positioned supine upon the operating table. General anesthesia was induced, and the patient was intubated without complications. The left arm was tucked. The patient's abdomen was prepped with chlorhexidine and draped in standard sterile fashion. A timeout was performed, correctly identifying patient, procedure, site and side of surgery. All were in agreement. Access to the peritoneal cavity was gained safely through an incision in the left upper quadrant using the Optiview technique. The abdomen was examined which demonstrated no injury to the bowel. Pneumoperitoneum was achieved. A 12 cm port was placed in the left lower quadrant under direct visualization. A 5 mm suprapubic port was also placed. We then placed the patient in Trendelenburg with right side up. The appendix was located in [ ] and noted to be [ ]. A window was created with blunt dissection between the appendix and mesoappendix. The base of the appendix was transected with an Ethicon 45mm blue load Echelon Flex powered laparoscopic stapler. The mesoappendix was dissected using a Harmonic scalpel. The abdomen was examined thoroughly was deemed hemostatic. The 12mm port was extended to accommodate the large appendix. The appendix was removed in an EndoCatch bag. The abdomen was desufflated. A fascial closure was performed at the LLQ port site using an 0-Vicryl running stitch. Skin for all three incisions was approximated using 4-0 Monocryl and dressed with Dermabond. Instrument and sponge counts were correct at the end of the procedure. The patient was extubated in the OR and transferred to the PACU in stable condition. The attending surgeon was present and scrubbed during the entire procedure.

open inguinal herniorrhaphy - KC Author: Garrett Skinner Service: GS (white) Copy template

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position. General anesthesia was induced and patient was intubated without issue. The patient was secured to the table with straps and all boney areas padded. The left inguinal area was prepped and draped in normal sterile fashion with Ioban. A timeout was done and all were in agreement. Incision was made over the medial aspect just above the inguinal ligament ligament. Incision was carried down through Scarpa's fascia external bleak was identified. This was opened along its fibers sharply with Metzenbaum along the length of the inguinal canal. The ilioinguinal nerve was identified and protected the cord was gently dissected away from the external oblique fascia and it was encircled with a Penrose drain. No direct hernia was noted. The cord was opened at the level of the cremasterics along their direction. The vas deferens and pampiniform plexus were identified and protected. A large indirect hernia was noted without any contents in the sac. This was gently and meticulously freed from the cord. It was simply reduced into the internal ring and the internal ring was closed slightly with interrupted 2-0 Vicryl in order to prevent the sac from coming back out. Polypropylene mesh was fashioned and was secured to the periosteum of the pubic tubercle with a single interrupted 0 PDS stitch. It was then secured to the conjoined tendon and internal oblique on the superior aspect of the floor and then to the shelving edge of the inguinal ligament on the inferior aspect all with interrupted 0 PDS. The internal ring was recreated with the tails of the mesh secured with 0 PDS on either side of the ring. It was not too tight. Hemostasis was achieved with electrocautery. External oblique was closed with running 2-0 Vicryl. Local field block was done with 1% lidocaine without epi. Scarpa's fascia was closed with interrupted Vicryl. Deep dermal was closed with interrupted Vicryl. It was closed with 4-0 Vicryl. The wound was dressed with Dermabond. The patient was awakened from anesthesia next day without issue and transported to PACU in stable condition.