|
Patient Name
|
Facility
|
|
Surgeon
|
|
|
No Assistant
|
Yes Assistant
|
|
Anesthesia
|
Anesthesiologist
|
|
Pre-Operative Diagnosis
• • •
|
Pre-Operative Diagnosis Comments
|
|
Post Operative Diagnosis
|
Post Operative Diagnosis Comment
|
|
Procedure
• • •
|
Other Procedure
|
|
Complications
• • •
|
Complications Comments
|
|
Specimen
|
Specimen Comments
|
|
Fluids (IV/ Urine)
/
|
Liposuction Infiltrate/ Aspirate
/
|
|
Condition
|
Condition Comments
|
|
Anesthesia Time
|
Surgery Time
|
|
|
|
|
Indication
• • •
|
Indication Comments
|
|
Exam
• • •
|
Exam Comments
|
|
Recommendation
• • •
|
Recommendation Comments
|
|
Procedure Agreed To
• • •
|
Procedure Agreed to Comments
|
|
Risks, Benefits Alternatives
|
RIsks Comments
|
|
Informed Consent Given
|
Informed Consent Comments
|
|
|
|
|
Pre-Operative Discussion
|
|
|
|
|
|
Supine position
|
|
|
General Anesthesia
|
SCD's and Pillow
|
|
LMA or ETT
|
Foley Catheter
|
|
Face Prepped and Draped
|
Local Infiltration
|
|
|
|
|
Incisions
• • •
|
|
|
Septum Exposed
|
Septum Exposed Comments
|
|
Septal Cartilage Harvest
|
Septal Cartilage Harvest Comment
|
|
Removal of Deviated Septum
|
Deviated Septum Comments
|
|
Cartilage Graft Harvested
|
Cartilage Graft Comments
|
|
Removal of Cartilage and Bone Spurs
|
Removal of Cartilage and Bone Spurs Comments
|
|
|
|
|
Separation of ULC from Septum
|
Separation of ULC Comments
|
|
Component Reduction of Dorsum
|
Component Reduction of Dorsum Comments
|
|
Bilateral Osteotomy
|
Osteotomies Comments
|
|
|
|
|
Cephalic Trim
|
Cephalic Trim Comments
|
|
Tip sutures
|
Tip Sutures Comments
|
|
|
|
|
|
|
|
Alar Wedge Resection
|
Alar Wedge Resection Comments
|
|
|
|
|
Suture Closure
|
Suture Closure Comments
|
|
Removal of Packing
|
Removal of Packing Comments
|
|
|
|
|
Turbinate Infracture
|
Turbinate Infracture Comments
|
|
Steristrips and Splint
|
Steristrips and Splint Comments
|
|
Other Maneuvers Comments
|
|
|
|
|
|
Emergence and Extubation
|
|
|
End of Procedure Comments
|
|
