Please note these are examples, read through the entire op report to ensure your Op report is accurate according to what you actually did
ESTIMATED BLOOD LOSS:
TUBES AND DRAINS:
INDICATIONS FOR PROCEDURE: The patient is a yr old who has a history of . Dr. discussed the treatment options with patient who has agreed to have a Prior to the procedure today, the patient's history and physical was reviewed. Informed consent was obtained and all questions were satisfactorily answered. The risks and benefits of the procedure including were discussed, patient acknowledged and communicated understanding of these risks and wished to proceed with the procedure.
OPERATIVE DETAIL: The patient was transferred to the cystoscopy suite and placed on continuous pulse oximetry and cardiac monitoring by anesthesia. IV antibiotics were administered. IV sedation and general anesthetic were administered. The patient was placed in the dorsal lithotomy position and prepped and draped in sterile fashion. Time out was performed confirming patient, procedure, side, all in the room agreed. SCDs were on and functioning. A well lubricated french cystoscopic sheath with a degree lens was inserted into the urethral meatus and advance and advanced into the bladder. Care was taken to keep the urethra lumen in center of view to minimize trauma to the urethra. In the urethra there The prostate . Upon entering the bladder, the bladder was drained. Urine was sent for culture. The bladder was then partially filled and evaluated in a panendoscopic fashion There were mucosal lesions, trabeculations, diverticulum, stones and tumors. Our attention was directed towards the ureteral orifice which we cannulated with and shot about and used fluoroscopy to delineate the collecting system on the There was We then removed the open ended ureteral catheter from the ureteral orifice and observed drainage of the collecting system by direct visualization and with fluoroscopy. There was drainage of the collecting system. We then directed our attention to the ureteral orifice which we cannulated with and shot about and used fluoroscopy to delineate the collecting system on the There was We then removed the open ended ureteral catheter from the ureteral orifice and observed drainage of the collecting system by direct visualization and with fluoroscopy. There was drainage of the collecting system. The bladder was drained, all parts of the cystoscopic sheath, cystoscope and instruments were intact and removed from the patient. The amount of fluid drained from the bladder was the expected amount given the amount of fluid irrigated into the bladder. The patient's abdomen was palpated and there was no change in physical exam from before the procedure and patient was awakened by anesthesia and transferred to PACU in stable condition. Patient tolerated the procedure well and was transferred to the PACU in stable condition.. Please note that Dr. was present throughout the entire length of the procedure.
PLAN: The patient will be after meeting anesthesia criteria. Patient was given given prescriptions for . The patient understands if there is any nausea, vomiting, fever, chills or develops gross hematuria, persistent or new pain or symptoms to come back to the Emergency Room for evaluation by urologic surgery.Patient will follow up with Dr. in