General Practitioner Template

Minor Surgical Procedure

About this template

This Minor Surgical Procedure template is designed for General Practitioners and nurses to document minor surgical interventions such as the excision of skin lesions. It includes sections for patient information, pre-operative assessment, procedure details, and post-operative care instructions. This template ensures comprehensive documentation, aiding in patient care continuity and legal compliance. Ideal for minor surgical procedures, it helps clinicians efficiently capture all necessary details, from clinical indications to follow-up care. This template is optimized for use with Heidi, an AI medical scribe, ensuring accurate and thorough medical records.

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Patient Name: John Doe Date of Birth: 01/01/1980 Date of Visit: 10/10/2023 Medical Record Number: 123456 Visit Type: Minor Surgical Procedure Procedure Performed: Excision of Skin Lesion Procedure Date: 10/10/2023 Indication for Procedure: Clinical Reason: Removal of suspicious skin lesion Previous Management: Topical treatments, monitoring Pre-Operative Assessment: Medical History: Relevant Past Medical History: Hypertension Allergies: Allergic to penicillin Medications: Lisinopril 10 mg daily Physical Examination: Site of Procedure: Left forearm Description of Lesion/Area: 1 cm pigmented lesion, no signs of infection Other Relevant Findings: Normal general examination Informed Consent: Consent Obtained: Yes Details Discussed: Procedure details, potential risks, benefits, and aftercare Procedure Details: Procedure Performed: Type of Procedure: Excision of skin lesion Anaesthesia Used: Local anaesthesia - 1% lidocaine Technique: Lesion excised with margins, site cleaned and sutured Instruments Used: Scalpel, forceps, sutures Duration of Procedure: 15 minutes Findings: Pre-Operative: Lesion appeared benign, no signs of ulceration Intra-Operative: Lesion excised with clear margins Post-Operative: Site well-hemostatized, no excessive bleeding Specimen Handling: Type of Specimen: Skin lesion Sent for Histopathology: Yes Specimen Labeling: Patient’s name, procedure date Post-Operative Instructions: Care Instructions: Wound Care: Keep the area clean and dry, apply antibiotic ointment as prescribed Dressings: Change dressing daily or if it becomes wet Signs of Complications: Redness, swelling, increased pain, fever Activity Restrictions: Avoid strenuous activity for 1 week Pain Management: Medications Prescribed: Paracetamol 500 mg, take as needed for pain Dosage Instructions: 1 tablet every 6 hours as needed Follow-Up: Appointment for Suture Removal: 10/17/2023 Date for Results Review: 10/24/2023 Emergency Contact Information: Contact Details: Provided patient with contact details for any concerns or emergencies. Patient Education: Information Provided: Wound Care Instructions: Written instructions provided Signs of Complications: Discussed verbally and written information provided Follow-Up Appointment: Confirmed with patient and written information given Signature: Dr. Thomas Kelly General Practitioner [Provider’s Contact Information] Date: 10/10/2023

Patient Name: [Patient’s Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Date of Birth: [DOB] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Date of Visit: [Date] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Medical Record Number: [MRN] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Visit Type: Minor Surgical Procedure Procedure Performed: [Name of Procedure, e.g., Excision of Skin Lesion] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Procedure Date: [Date of Procedure] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Indication for Procedure: Clinical Reason: [e.g., removal of suspicious skin lesion, treatment of ingrown toenail, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Previous Management: [e.g., topical treatments, monitoring] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Pre-Operative Assessment: Medical History: Relevant Past Medical History: [e.g., diabetes, hypertension] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Allergies: [e.g., allergic to penicillin] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Medications: [List current medications] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Physical Examination: Site of Procedure: [e.g., left forearm] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Description of Lesion/Area: [e.g., 1 cm pigmented lesion, no signs of infection] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Other Relevant Findings: [e.g., normal general examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Informed Consent: Consent Obtained: Yes Details Discussed: [e.g., procedure details, potential risks, benefits, and aftercare] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Procedure Details: Procedure Performed: Type of Procedure: [e.g., Excision of skin lesion] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Anaesthesia Used: [e.g., Local anaesthesia - 1% lidocaine] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Technique: [e.g., Lesion excised with margins, site cleaned and sutured] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Instruments Used: [e.g., Scalpel, forceps, sutures] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Duration of Procedure: [e.g., 15 minutes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Findings: Pre-Operative: [e.g., lesion appeared benign, no signs of ulceration] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Intra-Operative: [e.g., lesion excised with clear margins] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Post-Operative: [e.g., site well-hemostatized, no excessive bleeding] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Specimen Handling: Type of Specimen: [e.g., skin lesion] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Sent for Histopathology: Yes Specimen Labeling: [e.g., patient’s name, procedure date] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Post-Operative Instructions: Care Instructions: Wound Care: [e.g., Keep the area clean and dry, apply antibiotic ointment as prescribed] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Dressings: [e.g., Change dressing daily or if it becomes wet] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Signs of Complications: [e.g., redness, swelling, increased pain, fever] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Activity Restrictions: [e.g., Avoid strenuous activity for 1 week] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Pain Management: Medications Prescribed: [e.g., Paracetamol 500 mg, take as needed for pain] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Dosage Instructions: [e.g., 1 tablet every 6 hours as needed] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Follow-Up: Appointment for Suture Removal: [Date, if applicable] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Date for Results Review: [Date, when histopathology results will be discussed] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Emergency Contact Information: Contact Details: Provided patient with contact details for any concerns or emergencies. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Patient Education: Information Provided: Wound Care Instructions: Written instructions provided Signs of Complications: Discussed verbally and written information provided Follow-Up Appointment: Confirmed with patient and written information given Signature: [Provider’s Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Provider’s Title] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Provider’s Contact Information] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Date: [Date of Documentation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)(Use as many bullet points as needed to capture all the relevant information from the transcript.)

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Specialty

General Practitioner

Used

192 times

Type

Note

Last edited

9/6/2024

Created by

Kieran Dang

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