Sample IP chart 1 OP reports

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OPERATIVE REPORT

03/06

Neurointerventional Procedure Note

Procedure Name: Diagnostic cerebral angiogram

Indications: left MCA aneurysm

Preoperative Diagnosis:  Giant left MCa aneurysm

Postoperative Diagnosis: Just under 30mm left MCa aneurysm arising from distal left M1 segment. Small parent vessel.

 

Pre-Procedure:

Pre Procedure Verification

Procedure Name: Cerebral Angiogram

PRE SEDATION CHECKLIST MD

Mallampati Airway Assessment: (EASY) VISUALIZATION OF THE SOFT PALATE, FAUCES, UVULA, ANTERIOR AND POSTERIOR PILLARS

Heart Exam: REG RATE

Lung Exam: CLEAR BILATERALLY

ASA Score: CLASS I-NORMAL HEALTHY PATIENT

NPO Status Liquids: 0000

NPO Status Solids: 0000

Intended level of sedation: LEVEL II MODERATE SEDATION

Pertinent Labs Reviewed: YES

Procedure and Recovery Code Status reviewed with patient and/or responsible party: FULL CODE FOR PROCEDURE AND RECOVERY

Consent for Procedure: YES

 

Informed Consent:

Written informed consent was obtained.  Please see pre-procedure note for full details.  The RISKS discussed with the patient include, but are not limited to: death, stroke, vessel damage/injury including dissection or perforation, need for emergency surgery, bleeding, infection, kidney damage, allergic reaction, radiation-induced hair loss/alopecia, equipment/device failure, inability to retrieve/remove device or equipment, as well as other, unforeseeable complications.

The BENEFITS of the procedure are that it will aid in the diagnosis and/or management of the patient's medical condition.  The ALTERNATIVES are that the patient may freely decide not to undergo this procedure.

All questions that the patient has regarding this procedure have been completely explained to their satisfaction and to the best of my ability. I am convinced that the patient understands the risks, benefits and alternatives of this procedure and that the patient wishes to proceed.  The hospital consent form was also been signed and and this was witnessed by a third party.

 

Technique/Prep:   Standard sterile technique; double-flush technique with heparinized saline (4,000units/liter normal saline). See dictated report for full details.

 

Vessels Injected:

Right Common femoral artery

Right internal carotid

Left internal carotid +3DRA

Left external carotid

Left vertebral

 

 

Findings (PRELIMINARY PLEASE SEE FINAL REPORT FOR FURTHER DETAILS):

Just under 30mm left MCa aneurysm arising from distal left M1 segment. Small parent vessel.

 

Procedural Sedation: 

The patient was re-evaluated immediately prior to sedation and remained a candidate for sedation. 

I have reviewed the electronic medication administration record for this procedure, and the documented sedation medications are what I have ordered and were administered in my presence.

 EBL:  Less than 5 ml 

Intraopertive medications:

            1% Lidocaine 5 ml subcutaneously

            IV Heparin: None 

            IA Verapamil: None 

Groin Closure device: MYNX

Specimen:  None

Complications:  none

Condition:  Stable 

Disposition:

1.       Recovery.  Patient to return to ICU. Groin orders written. D/W Dr. CCCDDD who will garner open surgical opinion.

 

OPERATIVE REPORT

03/06

Neurointerventional Procedure Note

Procedure Name: Diagnostic cerebral angiogram and aneurysm treatment

Indications: giant left MCA aneurysm

Preoperative Diagnosis:  Giant left MCA aneurysm

Postoperative Diagnosis: Same, now s/p Pipeline/coil embozliation.

 

Pre-Procedure:

Pre Procedure Verification

Two (2) patient identifiers (ID) verified: Patient Name;Medical Record Number

ID Band Verified and in Place: Yes

Correct Procedure Verified?: Yes

Procedure Name: embolization

SITE Verified: Yes

Site marked by Provider performing procedure: Yes

Accurate consent signed and available: Yes

Relevant documentation in chart?: Yes

Relevant images and results labeled and displayed: Yes

Implants, Equipment or Special Requirements Available: Not Applicable

Are required blood products available: Not Applicable

PRE SEDATION CHECKLIST MD

Mallampati Airway Assessment: (EASY) VISUALIZATION OF THE SOFT PALATE, FAUCES, UVULA, ANTERIOR AND POSTERIOR PILLARS

Heart Exam: REG RATE

Lung Exam: CLEAR BILATERALLY

ASA Score: CLASS I-NORMAL HEALTHY PATIENT

NPO Status Liquids: 0603

NPO Status Solids: 2359

Intended level of sedation: LEVEL II MODERATE SEDATION

Pertinent Labs Reviewed: YES

Procedure and Recovery Code Status reviewed with patient and/or responsible party: FULL CODE FOR PROCEDURE AND RECOVERY

Consent for Procedure: YES

 

Informed Consent:

Written informed consent was obtained.  Please see pre-procedure note for full details.  The RISKS discussed with the patient include, but are not limited to: death, stroke, vessel damage/injury including dissection or perforation, need for emergency surgery, bleeding, infection, kidney damage, allergic reaction, radiation-induced hair loss/alopecia, equipment/device failure, inability to retrieve/remove device or equipment, as well as other, unforeseeable complications.

The BENEFITS of the procedure are that it will aid in the diagnosis and/or management of the patient's medical condition.  The ALTERNATIVES are that the patient may freely decide not to undergo this procedure.

All questions that the patient has regarding this procedure have been completely explained to their satisfaction and to the best of my ability. I am convinced that the patient understands the risks, benefits and alternatives of this procedure and that the patient wishes to proceed.  The hospital consent form was also been signed and and this was witnessed by a third party.

 

Technique/Prep:   Standard sterile technique; double-flush technique with heparinized saline (4,000units/liter normal saline). See dictated report for full details.

 

Vessels Injected:

Right Common femoral artery

Left internal carotid

 

Findings (PRELIMINARY PLEASE SEE FINAL REPORT FOR FURTHER DETAILS):

Giant left MCA aneurysm, now s/p Pipeline/coil embozliation.

 Procedural Sedation:

GA/ETT with Dr. BBB

 

EBL:  Less than 25 ml 

Intraopertive medications:

            1% Lidocaine 5 ml subcutaneously

            IV Heparin: 5,000 units

            IA Verapamil: 3 mg LICa

Groin Closure device:MYNX

Implants: Pipeline embolization device 2.5mm x 18mm and detachable microcoils in aneurysm. All materia;s are MRI safe.

Specimen:  None

Complications:  none

Condition:  Stable 

Disposition:

1. Recovery.  Patient to transfer to ICU.

DAPT written for.

Continue steroids. 

At end of procedure, pt on cart, extubated, following symmetrically with all 4 and with fluent speech.

 

OPERATIVE REPORT

03/08

Neurointerventional Procedure Note

Procedure Name: Diagnostic cerebral angiogram

Indications: left MCA aneurysm

Preoperative Diagnosis:  Giant left MCa aneurysm

Postoperative Diagnosis: Just under 30mm left MCa aneurysm arising from distal left M1 segment. Small parent vessel.

 

Pre-Procedure:

Pre Procedure Verification

Procedure Name: Cerebral Angiogram

PRE SEDATION CHECKLIST MD

Mallampati Airway Assessment: (EASY) VISUALIZATION OF THE SOFT PALATE, FAUCES, UVULA, ANTERIOR AND POSTERIOR PILLARS

Heart Exam: REG RATE

Lung Exam: CLEAR BILATERALLY

ASA Score: CLASS I-NORMAL HEALTHY PATIENT

NPO Status Liquids: 0000

NPO Status Solids: 0000

Intended level of sedation: LEVEL II MODERATE SEDATION

Pertinent Labs Reviewed: YES

Procedure and Recovery Code Status reviewed with patient and/or responsible party: FULL CODE FOR PROCEDURE AND RECOVERY

Consent for Procedure: YES

 

Informed Consent:

Written informed consent was obtained.  Please see pre-procedure note for full details.  The RISKS discussed with the patient include, but are not limited to: death, stroke, vessel damage/injury including dissection or perforation, need for emergency surgery, bleeding, infection, kidney damage, allergic reaction, radiation-induced hair loss/alopecia, equipment/device failure, inability to retrieve/remove device or equipment, as well as other, unforeseeable complications.

The BENEFITS of the procedure are that it will aid in the diagnosis and/or management of the patient's medical condition.  The ALTERNATIVES are that the patient may freely decide not to undergo this procedure.

All questions that the patient has regarding this procedure have been completely explained to their satisfaction and to the best of my ability. I am convinced that the patient understands the risks, benefits and alternatives of this procedure and that the patient wishes to proceed.  The hospital consent form was also been signed and and this was witnessed by a third party.

 

Technique/Prep:   Standard sterile technique; double-flush technique with heparinized saline (4,000units/liter normal saline). See dictated report for full details.

 Vessels Injected:

Right Common femoral artery

Right internal carotid

Left internal carotid +3DRA

Left external carotid

Left vertebral

  

Findings (PRELIMINARY PLEASE SEE FINAL REPORT FOR FURTHER DETAILS):

Just under 30mm left MCa aneurysm arising from distal left M1 segment. Small parent vessel.

 

Procedural Sedation: 

The patient was re-evaluated immediately prior to sedation and remained a candidate for sedation. 

I have reviewed the electronic medication administration record for this procedure, and the documented sedation medications are what I have ordered and were administered in my presence.  

EBL:  Less than 5 ml 

Intraopertive medications:

            1% Lidocaine 5 ml subcutaneously

            IV Heparin: None 

            IA Verapamil: None 

Groin Closure device: MYNX

Specimen:  None

Complications:  none

Condition:  Stable 

 

OPERATIVE REPORT

03/08

Neurointerventional Procedure Note

Procedure Name: Diagnostic cerebral angiogram and aneurysm treatment

Indications: giant left MCA aneurysm

Preoperative Diagnosis:  Giant left MCA aneurysm

Postoperative Diagnosis: Same, now s/p Pipeline/coil embozliation.

 

Pre-Procedure:

Pre Procedure Verification

Two (2) patient identifiers (ID) verified: Patient Name;Medical Record Number

ID Band Verified and in Place: Yes

Correct Procedure Verified?: Yes

Procedure Name: embolization

SITE Verified: Yes

Site marked by Provider performing procedure: Yes

Accurate consent signed and available: Yes

Relevant documentation in chart?: Yes

Relevant images and results labeled and displayed: Yes

Implants, Equipment or Special Requirements Available: Not Applicable

Are required blood products available: Not Applicable

PRE SEDATION CHECKLIST MD

Mallampati Airway Assessment: (EASY) VISUALIZATION OF THE SOFT PALATE, FAUCES, UVULA, ANTERIOR AND POSTERIOR PILLARS

Heart Exam: REG RATE

Lung Exam: CLEAR BILATERALLY

ASA Score: CLASS I-NORMAL HEALTHY PATIENT

NPO Status Liquids: 0603

NPO Status Solids: 2359

Intended level of sedation: LEVEL II MODERATE SEDATION

Pertinent Labs Reviewed: YES

Procedure and Recovery Code Status reviewed with patient and/or responsible party: FULL CODE FOR PROCEDURE AND RECOVERY

Consent for Procedure: YES

 

Informed Consent:

Written informed consent was obtained.  Please see pre-procedure note for full details.  The RISKS discussed with the patient include, but are not limited to: death, stroke, vessel damage/injury including dissection or perforation, need for emergency surgery, bleeding, infection, kidney damage, allergic reaction, radiation-induced hair loss/alopecia, equipment/device failure, inability to retrieve/remove device or equipment, as well as other, unforeseeable complications.

The BENEFITS of the procedure are that it will aid in the diagnosis and/or management of the patient's medical condition.  The ALTERNATIVES are that the patient may freely decide not to undergo this procedure.

All questions that the patient has regarding this procedure have been completely explained to their satisfaction and to the best of my ability. I am convinced that the patient understands the risks, benefits and alternatives of this procedure and that the patient wishes to proceed.  The hospital consent form was also been signed and and this was witnessed by a third party.

 

Technique/Prep:   Standard sterile technique; double-flush technique with heparinized saline (4,000units/liter normal saline). See dictated report for full details.

 

Vessels Injected:

Right Common femoral artery

Left internal carotid 

 

Findings (PRELIMINARY PLEASE SEE FINAL REPORT FOR FURTHER DETAILS):

Giant left MCA aneurysm, now s/p Pipeline/coil embozliation.

 

Procedural Sedation:

GA/ETT with Dr.

 

EBL:  Less than 25 ml 

Intraopertive medications:

            1% Lidocaine 5 ml subcutaneously

            IV Heparin: 5,000 units

            IA Verapamil: 3 mg LICa

Groin Closure device:MYNX

Implants: Pipeline embolization device 2.5mm x 18mm and detachable microcoils in aneurysm. All materia;s are MRI safe.

Specimen:  None

Complications:  none

Condition:  Stable 

Disposition:

1. Recovery.  Patient to transfer to ICU.

DAPT written for.

Continue steroids.

 At end of procedure, pt on cart, extubated, following symmetrically with all 4 and with fluent speech