Operative Note (Ortho)

**PATIENT NAME:** 

**DATE OF SURGERY:** 

**TIME IN/OUT OF OR:** 

**MEDICAL RECORD NUMBER:** 

**SURGEON(S):** 

**ASSISTANTS:** 

**ANESTHETIST:** 

**SCRUB/CIRCULATING NURSE:** 

**PROCEDURE PERFORMED:** 

**LATERALITY (LEFT/RIGHT/BILATERAL):** 

**PATIENT POSITIONING:** 

**TOURNIQUET DETAILS:**

**ANESTHESIA TYPE:** 

**PRE-OP DIAGNOSIS:** 

**POST-OP DIAGNOSIS:** 

**INTRAOPERATIVE FINDINGS:** 

**PROCEDURE DESCRIPTION:** 

**IMPLANTS USED ** 

**INTRAOPERATIVE IMAGING:**

**REDUCTION AND ALIGNMENT:**

**NEUROVASCULAR EXAM:**

**DRAINS/LINES PLACED:** 

**ESTIMATED BLOOD LOSS:** 

**SPECIMENS SENT:** 

**INTRAOPERATIVE COMPLICATIONS:** 

**DISPOSITION :**

**POST-OPERATIVE PLAN:**
- Pain Management: The patient is currently taking Celebrex, to be completed on Sunday, and will transition to Advil and Tylenol as needed for pain control.
- Wound Care: The incision is healing well.
- Activity and Weight-Bearing Status: The patient is to remain non-weight bearing, allowing only touch-down weight for balance, until follow-up x-rays confirm adequate healing. The range of motion brace will remain in use until sufficient healing is demonstrated.
- Other Relevant Information: The patient has been advised to continue range of motion exercises at home and to use compression socks in the morning to help manage swelling. A referral for formal physical therapy was provided and accepted.

Alex Chen