Dr. Gordon prefers this template and will reformat yours to look like this:

Plastic Surgery Operative Report

Name: XXXXXX
Date: XXXX
SSN: XXXX

Pre-operative diagnosis: XXXX

Post-operative diagnosis: XXX

Procedure: XXXXX

Attending Surgeon: Michael J.V. Gordon, M.D.

Resident Assistants: Jonathan Freedman, M.D.


Operative indications: XXXXXXXXXXXX

The risks and benefits of surgery were discussed with the patient including scar, infection, pain and bleeding. Injury to nearby structures and need for additional procedures were also discussed.


Operative description: The patient was marked in the pre-operative suite and brought to the operating room. The patient was transferred to the operating room table and secured with all bony prominences padded. SCDs were placed and general anesthesia was started. Pre-operative antibiotics were given and the patient was prepped and draped in sterile fashion.

XXXXXXXXXXXXXX

The patient was awakened from anesthesia and extubated without issue. The patient was brought to PACU and discharged home. All counts were correct. There were no complications. Dr. Gordon was present for the entirety of the procedure.
Implants: none

Complications: none

Findings: XXXXX

Blood loss: minimal

Specimens: none

RESIDENT NAME
Plastic Surgery
Pager LAST FOUR

The carpal tunnel incision was closed with 5-0 vicryl deep dermals followed by 5-0 nylon simple interupted sutures. The cubital tunnel was closed with 5-0 vicryl sutures followed by 5-0 monocryl running subcuticular sutures.

Dr. Mathes Post-Operative Instructions
Breast Tissue Expanders

Dressing

• You have a soft surgical bra in place. You may change the gauze or pads inside the bra as needed if they become damp or soiled.
• 48 hours after surgery, you may remove the surgical bra and dressings, and shower. Leave Steri-strips in-place, and pat them dry after showering. Do not submerge in water (tub bath, pool, hot tub) for 4 weeks after surgery.
• You may wear the surgical bra as needed for comfort, or you may go bra-less.
• If needed, apply antibiotic creme to any blistered areas, twice a day.
• NO ICE to the breasts.

Drains

• You will be sent home from the hospital with drains in place. Empty the drains as instructed twice a day, and record the amount emptied each time, for each drain.
• Bring the record with you to your post-op appointment, as this will determine if the drains may be removed. Drains are removed when draining less than 30cc per day.
• Make sure the bulbs are collapsed on suction after you empty them.
• You may shower with your drains, but be careful not to accidentally pull them out. Do not take a tub bath until after your drains are removed and the drain sites are healed.

Pain

• You will have some pain and discomfort from your surgery
• Take the pain medication that you have been prescribed
• If you have extreme pain not relieved by the pain medicine, or if you have swelling, fever, redness or drainage from your wound, call immediately

Activity

• You should begin walking as much as possible immediately after surgery.
• Refrain from lifting greater than 10 pounds, and strenuous activity or exercise, for 4 weeks after surgery.
• Do NOT sleep on reconstructed breasts—sleep on back, only.

Post-operative appointment:
7-10 days after your surgery day. If you don’t already have your post-op appointment scheduled, please call the number below to schedule with Dr. Mathes:

The Plastic Surgery clinic, E building 3rd Floor - Maroon Peak
720-857-5817

Date:
Time:

Prescriptions given:
Pain Medicine:
Antibiotics:
Anti-nausea medicine:

If you have further questions, please call the Plastic Surgery Clinic at 720-857-5817. If you require immediate attention after business hours, call the hospital 24-Hour Emergency Nurse Line at (866) 369-8020.