Dentistry GA operative report

Document Information

Document Type: [Type of document, e.g., Dentistry Operative Report] Service Date/Time: [Date and time of service (DD-MMM-YYYY HH:mm)] Patient Name: [patient name] Date of Birth: [patient's date of birth (DD-MMM-YYYY)] Result Status: [Status of document, e.g., Auth (Verified)] Document Subject: [Subject of the document, e.g., Operative Note] Facility: [Name of location] Sign Information: [List of signatories with names, credentials, and signing date/time]

Surgery Details

Date of Surgery: [Date of surgery (DD-MMM-YYYY)] Surgeon/Proceduralist: [Name, credentials, and role] Assistant(s): [Name(s), credentials, and role(s)] Anesthesia (General): [Name(s), credentials, and role(s) of anesthesia providers] OR Nurse: [Name(s)]

Clinical Preamble

Pre-operative discussion with the guardian about the treatment plan, guardian verbalized understanding, operative consent obtained.

Clinical Findings

[Provide a list with bullets, of the clinical examination findings such as dentition status, previously extracted teeth, teeth with caries or other pathology, soft tissue condition, and signs of infection or abscess.]

Radiographic Findings

[Provide a list with bullets, of the radiographic examination findings including correlation with clinical findings, presence or absence of bone pathology, periapical radiolucency, and extent of caries involvement.]

Preoperative Diagnosis

Preoperative Diagnosis: [Preoperative diagnosis]

Treatment Performed

[Provide a list with dashes of treatments completed under isolation or other conditions, including restorations (type and teeth), crowns placed, extractions performed, and any special considerations due to patient history.] (For example: - 55 occlusal lingual composite with indirect pulp therapy - 61 all surface composite size 3 - Indirect pulp therapy was completed on teeth 52, 51 and 61) [Include any relevant notes about treatment decisions based on patient history.]

Hemostasis and Anesthesia

Hemostasis was achieved with: [Materials or methods used] Total local anesthetic administered: [Amount and type of anesthetic]

Postoperative Instructions and Disposition

The oral cavity was thoroughly debrided, topical fluoride applied and the throat pack removed. The patient was extubated and sent to PAR in good condition. Written and verbal post-operative instructions were reviewed with guardian. Post operative follow-up and all routine dental care will be scheduled at the Monarch pediatric dental centre.

Signatures

[doctor's name] [date of procedure}