Читать книгу Principles of Dentoalveolar Extractions - Seth Delpachitra - Страница 23

Following a surgical procedure, detailed clinical notes should be completed as soon as possible, listing all medications or anaesthetics administered and steps taken, the difficulty of the procedure, any intraoperative complications that arose, and any postoperative discussions with or instructions given to the patient. At a minimum, the operative note should include:

 Indications for the procedure and a summary of intraoperative findings.

 Type of anaesthesia used (relative anaesthesia, oral or IV sedation, general anaesthesia):specifically, the type of local anaesthesia, dose administered, concentration, and use of vasoconstrictors.

 A detailed procedural note, including:methods used for extraction (‘simple’ versus ‘surgical’), with a detailed description of each step;any complications encountered;difficulty of the procedure;haemostatic agents used;suture type;ease in obtaining haemostasis.

 Additional notes on any medications prescribed, including type, dose, and duration.

 Any postoperative orders that were given to the patient, and how they were transmitted (written, verbal, or both).

 The date and time of the follow‐up appointment.

The operative note must reflect a legal memorandum outlining the specific intraoperative details of every case; a good clinical note enables continuity of care, provides a basis for informative evidence for any future complaints or complications, and enhances communication between healthcare professionals.