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Operative Report
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Office
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Facility
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Lake Worth Surgery Center
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Other Facilities
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Case cancelled
• • •
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New Short Text Field
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Op report number
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Dictated
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Brief pre op interview
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Brief preop examination
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CATEGORIES
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INJECTIONS
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ABLATIONS
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NECK SURGERY
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LUMBAR SURGERY
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SACROILIAC SURGERY
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SHOULDER SURGERY
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KNEE SURGERY
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SURGERIES
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--------------------------------------------------------
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Bilateral SI Joint injection
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Bilateral SI Joint injection EXPAREL
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Right SI Joint injection
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Right SI Joint injection with EXPAREL
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Left SI Joint injection
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Left SI Joint injection with EXPAREL
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Conclusion
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General Injections
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See solutions injected at end of procedure (bottom of form)
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for all injections below.
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Hip joint injection
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Hip rotator cuff and trochanteric bursa injection
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Shoulder subacromial injection
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Knee joint injection
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Shoulder subacromial and trochanteric bursa hip cuff injection
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Right sub acrom and right troch bursa inj
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Left sub acrom and left troch bursa inj
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Right sub acrom and left troch bursa inj
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Left sub acrom and right troch bursa inj
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Shoulder and SI injection
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RIGHT shoulder subacromial and RIGHT SI injection
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LEFT shoulder subacromial and LEFT SI injection
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RIGHT shoulder subacromial and LEFT SI injection
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LEFT shoulder subacromial and RIGHT SI injection
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RIGHT shoulder subacromial and BILATERAL SI injection
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LEFT shoulder subacromial and BILATERAL SI injection
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Caudal Lumbar ESI
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Diagnosis
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Generic injection using contrast and fluoro: enter site
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Generic injection without contrast: enter site
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Generic injection (will appear after main procedure)
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Trigger point injection (describe location of injection)
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Injection procedure (enter site, joint etc.)
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Comments
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Fluoroscopy was used with contrast
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Medication injected and conclusion
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Medication injected:
• • •
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Comments
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Conclusion
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Sacroiliac Ablation with electrodes
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Bilateral SI Joint ablation
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Right SI Joint ablation
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Left SI Joint ablation
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SI joint fusion
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Bone dowels (SIFIX, Sibi)
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No implant (Infuse, Proteos, Osteoflo only)
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New Travis device with wings
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Bilateral sacroiliac fusion with new Travis device with wings and osteoflo
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Bilateral sacroiliac fusion with bone dowels and DBM
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Bilateral sacroiliac fusion with bone dowels and osteoflo
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Right sacroiliac fusion with bone dowels and osteoflo
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Left sacroiliac fusion with bone dowels and osteoflo
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RIGHT SI FUSION with bone dowels and generic dbm
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LEFT SI FUSION with bone dowels and generic dbm
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Bilateral sacroiliac fusion with Infuse and osteoflo
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Right sacroiliac fusion with Infuse and osteoflo
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Left sacroiliac fusion with Infuse and osteoflo
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Bilateral sacroiliac fusion with ProteIOS and osteoflo
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Right sacroiliac fusion with ProteIOS and osteoflo
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Left sacroiliac fusion with ProteIOS and osteoflo
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Bilateral sacroiliac fusion with ProteIOS, Osteoflo and Sibi bone dowel
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Right sacroiliac fusion with ProteIOS, osteoflo and Sibi bone dowel
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Left sacroiliac fusion with ProteIOS, osteoflo and Sibi bone dowel
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Comments
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Shoulder Intra Articular Injection
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Shoulder Intra Articular Injection
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Right shoulder Intra-articular injection: pick meds
• • •
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Left shoulder Intra-articular injection: pick meds
• • •
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Conclusion
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Knee Intra Articular Injection
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Right knee Intra-articular injection: pick meds
• • •
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Left knee Intra-articular injection: pick meds
• • •
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Conclusion
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Hip Rotator Cuff and Trochanteric Bursa Injection
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Hip rotator cuff and trochanteric bursa injection
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Conclusion
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Cervical Facet injection
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Cervical Rhizotomy
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Cervical Facet Injection
• • •
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Cervical Facet Rhizotomy
• • •
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Conclusion
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Conclusion
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Lumbar Facet injection
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Lumbar Rhizotomy
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Lumbar Facet Injection
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Lumbar Facet Rhizotomy
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Conclusion
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Conclusion
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Shoulder Surgery
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Pre op diagnosis
• • •
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Post op diagnosis
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Additional diagnosis:
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Surgeon - Assistant
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Operation
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Additional procedures
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Anesthesia
• • •
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Injection of Exparel
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Exparel shoulder block
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Generic Compications, Spec, EBL, Drains
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Specific Complications, EBL, Spec and Drains
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Generic indications
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Specific indications
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Diagnostics and Medical records reviewed
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Consent section
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New Short Text Field
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Significant Findings
• • •
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Additional significant findings
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Rotator cuff repair double row 1cm tear
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Shioulder arthroscopy with NO distal clavicle excision: Procedure in detail-select side
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Shoulder arthroscopy WITH distal clavicle excision: Procedure in detail-select side
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Acromioclavicular reconstruction with allograft: Procedure in detail-select side
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Remarks
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Knee Surgery
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Pre op diagnosis
• • •
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Additional diagnosis:
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Post op diagnosis
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Additional diagnosis:
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Surgeon - Assistant
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Operation
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Additional Procedures
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Anesthesia EBL Spec Comp etc routine
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Anesthesia
• • •
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Anesthesia Complications, EBL, Spec etc free text for different values
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Other
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Generic indications
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Customized indications
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Diagnostics and Medical records reviewed
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Consent section
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Significant findings
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Procedure in detail-select side
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Solutions injected to each site in the procedure:
• • •
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Solutions injected after procedure
• • •
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Conclusion
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Generic Surgery
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Preop diagnosis
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Postop diagnosis
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Procedure
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Surgeon - Assistant
• • •
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Anesthesia
• • •
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Generic Compications, Spec, EBL, Drains
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Specific Complications, EBL, Spec and Drains
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Generic indications
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Specific indications
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Diagnostics and Medical records reviewed
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Consent section
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Procedure
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Conclusion
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Cervical ACDF TDR
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Pre op diagnosis
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Neck pain
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Cervical radiculopathy
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Neural compression/stenosis
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C3-4 Spondylitis
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C3-4 disc herniation
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C3-4 disc disease
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C4-5 spondylitis
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C4-5 disc herniation
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4-5 disc disease
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C5-6 Spondylitis
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C5-6 disc herniation
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C5-6 disc disease
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C6-7 Spondylitis
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C6-7 disc herniation
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C6-7 disc disease
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Post op diagnosis
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Additional diagnosis:
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Operation
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Anterior approach to the cervical spine
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C3-4 cervical discectomy
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C3-4 implantation of interbody prosthesis
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C3-4 implantation of total disc replacement
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C3-4 implantation of locally harvested autograft bone for spine surgery (nonstructural)
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C3-4 implantation of DBM
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C3-4 cervical plating
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C4-5 cervical discectomy
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C4-5 implantation of interbody prosthesis
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C4-5 implantation of total disc replacement
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C4-5 implantation of locally harvested autograft bone for spine surgery (nonstructural)
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C4-5 implantation of DBM
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C4-5 cervical plating
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C5-6 cervical discectomy
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C5-6 implantation of total disc replacement
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C5-6 implantation of interbody prosthesis
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C5-6 implantation of locally harvested autograft bone for spine surgery (nonstructural)
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C5-6 implantation of DBM
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C5-6 cervical plating
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C6-7 cervical discectomy
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C6-7 implantation of total disc replacement
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C6-7 implantation of DBM
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C6-7 implantation of locally harvested autograft bone for spine surgery (nonstructural)
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C6-7 implantation of DBM
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C6-7 cervical plating
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Use of magnification with illumination
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Interpretation of intraoperative fluoroscopy
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Operation
• • •
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Surgeon - Assistant
• • •
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Generic Compications, Spec, EBL, Drains
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Generic with drain Compications, Spec, EBL, Drains
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Specific complications, EBL, Spec, drains etc
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Generic indications
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Specific indications
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Diagnostics and Medical records reviewed
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New Short Text Field
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Consent section
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Significant findings
• • •
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New Short Text Field
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Procedure in detail:
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Anterior approach
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At C3-4 the following was performed
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Discectomy template
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LDR ROI-C placement
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TDR Moby-C implantation
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At C4-5 the following was performed
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Discectomy template
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LDR ROI-C placement
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TDR Moby-C implantation
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At C5-6 the following was performed
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Discectomy template
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LDR ROI-C placement
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TDR Moby-C implantation
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At C6-7 the following was performed
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Discectomy template
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LDR ROI-C placement
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TDR Moby-C implantation
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Closure no drain
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Closure WITH PENROSE drain
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Carpal tunnel release
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Pre op diagnosis
• • •
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Additional diagnosis:
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Post op diagnosis
• • •
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Additional diagnosis:
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Operation:
• • •
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Additional procedures:
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Surgeon - Assistant
• • •
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Anesthesia
• • •
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Generic Compications, Spec, EBL, Drains
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Specific Complications, EBL, Spec and Drains
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Generic indications
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Specific indications
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Diagnostics and Medical records reviewed
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Consent section
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Significant findings
• • •
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Procedure in detail:
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Right carpal tunnel release
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Left carpal tunnel release
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Right trigger thumb release
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Left trigger thumb release
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New Single Select
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Misc injections
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Caudal ESI
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PRP injection
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Diagnosis
• • •
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Procedure
• • •
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