Clinical Experience Operative Case Summary: Enter Name of Procedure
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Transcript of Clinical Experience Operative Case Summary: Enter Name of Procedure
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Clinical ExperienceOperative Case Summary:Enter Name of Procedure
ST310/ST320Concorde Career College, Enter Campus
Student Name: Enter NameDate: Enter Due DateSurgeon: Enter Name
Preceptor: Enter Name
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Name of Procedure
• Choose the most challenging procedure scrubbed since the previous Clinical Conference, or first day of the term if First Clinical Conference.
• Receive an assigned procedure from the instructor if no cases scrubbed
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Definition of Procedure
• Include a detailed definition of the procedure
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Indications for Surgery
• List the specific indications (signs & symptoms, diagnostic results, preoperative diagnosis) that led to this surgical intervention
• These must be specific to the patient and not hypothetical
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Anesthesia Type
• What type of anesthesia was used (route of administration, agents, etc.)?
• Why was this chosen?
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Skin Prep
• Provide a detailed diagram of the skin prep perimeters used on this patient
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Surgical Incision
• Provide a detailed diagram of the incision site• Label the anatomy within the incision• What was this incision/approach chosen?
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Patient Position
• List the specific position used• List all supplies and equipment used• Why was this position chosen?
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Draping
• List all materials and the sequence of application
• Where there any special considerations made?
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Equipment
• List all equipment used and state why each was necessary
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Instrumentation
• List all basic and specialty instrumentation• Provide images and descriptions of three
particular instruments used in this procedure– Preferably items that were unfamiliar
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Supplies
• List all supplies needed and utilized– Use physician preference card as resource
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Pharmacology
• List ALL agents used and state their specific purpose during this procedure
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Mayo Setup
• Outline and diagram the specific Mayo stand setup used to facilitate this procedure
• List reasons why this setup was useful• How can the setup be improved?
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Sutures
• List all suture used on this procedure• List the physical characteristics for each• What types of suture needles were used?• In which tissues/wound layers was each
suture used?• What was the surgeon’s rational for specific
suture choice?
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Operative Procedural Steps
• Provide a detailed account of each step of the procedure– This section should mirror the surgeon’s operative
report in style and content.• Highlight specific anatomy and physiology and
provide detailed diagrams
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Drains & Dressing
• List any drains used and state the purpose of each
• List all dressing materials used• Outline the procedure used to dress this
wound
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Specimens & Implants
• List all surgical specimens• List all materials implanted into the wound
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Postoperative Diagnosis
• State the diagnosis• Did this change from the preoperative
diagnosis? If so, why?
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Possible Complications
• List all specific possible complications that may result from this procedure– Be specific
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Prognosis
• How is the patient expected to recover?• What is the wound class?• Are there any long-term effects to consider?• Will another operation be needed?
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Most Important Knowledge Learned
• What was the most interesting or valuable thing that you learned while scrubbing this procedure?
• How will this information help you in the field?
• Looking back, would you have done anything differently?