About this template
This Operation Note (Ortho) template is designed for orthopaedic surgeons to document surgical procedures efficiently. It includes sections for detailing the procedure carried out, steps for wound closure, and post-operative instructions. This template is ideal for surgeries such as arthroscopies, joint replacements, and fracture fixations. Using Heidi, this template ensures comprehensive and accurate documentation, enhancing patient care and streamlining the workflow for orthopaedic practices. Perfect for those searching for 'orthopaedic surgery documentation examples' or 'operation note templates for orthopaedic surgeons.'
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Procedure
The patient, a 45-year-old male, underwent a right knee arthroscopy with partial meniscectomy. The procedure was performed under general anesthesia. The arthroscope was introduced through the anterolateral portal, and a thorough examination of the knee joint was conducted. A complex tear of the medial meniscus was identified and resected using a shaver. The joint was irrigated, and no other intra-articular pathology was noted.
Closure
The portals were closed using 4-0 nylon sutures. Sterile dressings were applied, and the patient was transferred to the recovery room in stable condition.
Post-op instructions
The patient was advised to keep the surgical site clean and dry. Weight-bearing as tolerated with crutches was recommended for the first week. Pain management includes acetaminophen and ibuprofen as needed. The patient was instructed to follow up in two weeks for suture removal and further evaluation.
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