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Patient Name
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Procedure Name
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Pre Operative Diagnosis
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Post Operative Diagnosis Same
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Post Operative Diagnosis Comments
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Anesthesia
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Anesthesiologist
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Complications
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Complications Comments
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EBL
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Condition Stable
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Condition Comments
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Indication
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Indication Comments
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Risks, Benefits and Alternatives Discussed
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Risks, Benefits and Alternatives Comments
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Operative Plan Discussed with Patient
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Operative Plan Comments
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Supine on Table
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Abdomen Infiltrated
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Infiltration Comments
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Abdomen Prepped and Draped
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Incision Made
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Incision Comments
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Creation of First Subcutaneous Pocket
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First Pocket Comments
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Creation of Second Subcutaneous Pocket
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Second Pocket Comments
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Hemostasis
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Insertion of first naltrexone pellets
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First Insertion Comments
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Insertion of Second Set of Naltrexone Pellets
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Second Insertion Comments
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Incision Closed
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Incision Closure Comments
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Dressing
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Dressing Comments
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Sterile Gauze
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Additional Comments
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Skin Cleansed
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End of Procedure
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