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PREOP Dx
• • •
PreOp Dx Free text
Post Op Dx
• • •
Post Op Dx Free Text
Operation
• • •
Operation Free Text
Anesthesia
• • •
Time OUT
Location of Lesion(s)
Set up
Details
• • •
Details of the procedure
Deep closure
• • •
Deep closure stitch
• • •
Deep dermis suture
• • •
Skin closure stitich
• • •
Type of skin stitch
• • •
same for multiple lesions
Steri strips
Findings
• • •
Findings
Specimen(s) Resected
Weight of specimen
Sent to Path
EBL (cc's)
No complications
Complications Free Text
Urine Output
Lesion Excision
Surgery stop time
Specimen Resected
• • •
Anesthesia Stop Time
IV fluid
Reference Number
Surgery Start Time
Fill volume
Anesthesia Start Time
Reference number
Right Breast Implant
• • •
Fill Volume
Serial Number
Injection volume
Left Breast Implant
• • •
Aspirate volume
Serial Number
Injection Volume
lipo area #1
• • •
Aspiration Volume
Lipo area #2
• • •
Injection Volume
Lipo area #3
• • •
Aspiration Volume
Lipo Area #4
• • •
Injection Volume
Lipo Area #5
• • •
Aspiration Volume
Lipo Area #6
• • •
Injection Volume
Lipo Area #7
• • •
Aspiration Volume
Lipo Area #8
• • •
Injection Volume
Lipo Area #9
• • •
Aspiration Volume
Lipo Area #10
• • •
Injection Volume
Total Volume Injected
Aspiration Volume
Injection Volume
Aspiration Volume
Injection Volume
Aspiration Volume
Injection Volume
Aspiration Volume
Total Aspirate

Local Procedure Note Medical Form

Plastic Surgeon

Dr. Peterson Local Procedure Note

There are 12 copies in use.
Published: Jan. 20, 2016, 5:10 p.m.
Doctor: Dr. History Physical
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