DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: High-grade squamous intraepithelial lesion of the cervix.
POSTOPERATIVE DIAGNOSIS: High-grade squamous intraepithelial lesion of the cervix.
PROCEDURE PERFORMED: Loop electrosurgical excision procedure of the transformation zone.
SURGEON: John Doe, MD
ANESTHESIA: General.
FINDINGS: White epithelium at the transformation zone in the cervix.
ESTIMATED BLOOD LOSS: Negligible.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in the supine position on the operating table where general anesthesia was administered. She was then placed in the dorsal lithotomy position where exam under anesthesia was performed. She was prepped and draped in the usual manner. An insulated bivalve speculum was then inserted into the vagina to expose the cervix. The cervix was prepped with Betadine under direct visualization. It was then swabbed with acetic acid and visualized with the colposcope to delineate the abnormal area of the transformation zone. The cervix was infiltrated with diluted Pitressin solution, 5 units of Pitressin in 50 mL of sterile saline. Approximately 15 mL of this solution was utilized as the cervix was injected at several points around the periphery of the cervical os until the cervix was blanched, indicating vessel spasm. A 10 x 15 mm loop electrode was then obtained, and a cone biopsy was carried out using a blended current of 45 watts cutting and 45 watts coag. There was basically no bleeding encountered. After excision of the cone biopsy specimen, an additional area of surrounding epithelium was cauterized with the ball electrode. Small endocervical curettage was also taken with a Kevorkian curette. All instruments were removed. The patient was returned to the supine position. She was awakened from anesthesia without difficulty and transferred to the recovery room in good condition. She tolerated the procedure well with no complications.
Sample #2
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Persistent cervical intraepithelial neoplasia.
POSTOPERATIVE DIAGNOSIS: Persistent cervical intraepithelial neoplasia.
PROCEDURES PERFORMED:
1. Exam under anesthesia.
2. LEEP of the transformation zone.
3. Endocervical curettage.
SURGEON: John Doe, MD
ANESTHESIA: General.
FINDINGS: Normal size uterus with no adnexal masses. There is white epithelium of the transformation zone surrounding the os.
ESTIMATED BLOOD LOSS: Negligible.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in the supine position on the operating table where general anesthesia was administered. She was then placed in the dorsal lithotomy position where examination under anesthesia was performed. She was prepped and draped in usual manner for surgery. An insulated bivalve speculum was inserted into the vagina to expose the cervix. This was fitted with an evacuation system to remove any resultant smoke from the procedure. The cervix was prepped with Betadine, and it was then swabbed with acetic acid and viewed colposcopically to delineate the abnormal transformation zone. The cervix was then infiltrated with diluted Pitressin solution, 5 units in 50 mL of sterile saline. Approximately 12 mL of this solution were infiltrated at multiple points around the periphery of the cervix and the cervix was blanched nicely. A blue electrode was obtained and fitted with the guard at a setting of 45 watts cutting, 45 watts coag blend. It was used to excise the cone biopsy specimen. There was no bleeding encountered. The ball electrode was used to cauterize an additional peripheral area of epithelium. An endocervical curettage was taken. Again, no bleeding was encountered. After the endocervical curettage, the speculum was withdrawn. The procedure was terminated. The patient was returned to supine position, awakened from anesthesia without any difficulty and transferred back to same day surgery in good condition. She tolerated the procedure well with no complications.
LEEP Procedure Sample Report Pediatric Discharge Summary Sample Report #1
Neonatal / Infant Discharge Summary Sample Delivery Note Transcribed Sample Report
