Clinical ExperienceOperative Case Summary:Enter Name of Procedure

ST310/ST320Concorde Career College, Enter Campus

Student Name: Enter NameDate: Enter Due DateSurgeon: Enter Name

Preceptor: Enter Name

Name of Procedure

• Choose the most challenging procedure scrubbed since the previous Clinical Conference, or first day of the term if First Clinical Conference.

• Receive an assigned procedure from the instructor if no cases scrubbed

Definition of Procedure

• Include a detailed definition of the procedure

Indications for Surgery

• List the specific indications (signs & symptoms, diagnostic results, preoperative diagnosis) that led to this surgical intervention

• These must be specific to the patient and not hypothetical

Anesthesia Type

• What type of anesthesia was used (route of administration, agents, etc.)?

• Why was this chosen?

Skin Prep

• Provide a detailed diagram of the skin prep perimeters used on this patient

Surgical Incision

• Provide a detailed diagram of the incision site• Label the anatomy within the incision• What was this incision/approach chosen?

Patient Position

• List the specific position used• List all supplies and equipment used• Why was this position chosen?

Draping

• List all materials and the sequence of application

• Where there any special considerations made?

Equipment

• List all equipment used and state why each was necessary

Instrumentation

• List all basic and specialty instrumentation• Provide images and descriptions of three

particular instruments used in this procedure– Preferably items that were unfamiliar

Supplies

• List all supplies needed and utilized– Use physician preference card as resource

Pharmacology

• List ALL agents used and state their specific purpose during this procedure

Mayo Setup

• Outline and diagram the specific Mayo stand setup used to facilitate this procedure

• List reasons why this setup was useful• How can the setup be improved?

Sutures

• List all suture used on this procedure• List the physical characteristics for each• What types of suture needles were used?• In which tissues/wound layers was each

suture used?• What was the surgeon’s rational for specific

suture choice?

Operative Procedural Steps

• Provide a detailed account of each step of the procedure– This section should mirror the surgeon’s operative

report in style and content.• Highlight specific anatomy and physiology and

provide detailed diagrams

Drains & Dressing

• List any drains used and state the purpose of each

• List all dressing materials used• Outline the procedure used to dress this

wound

Specimens & Implants

• List all surgical specimens• List all materials implanted into the wound

Postoperative Diagnosis

• State the diagnosis• Did this change from the preoperative

diagnosis? If so, why?

Possible Complications

• List all specific possible complications that may result from this procedure– Be specific

Prognosis

• How is the patient expected to recover?• What is the wound class?• Are there any long-term effects to consider?• Will another operation be needed?

Most Important Knowledge Learned

• What was the most interesting or valuable thing that you learned while scrubbing this procedure?

• How will this information help you in the field?

• Looking back, would you have done anything differently?