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Brief Op Note
(often available on a preprinted form)
Date & Time
Pre-op Diagnosis
Post-op Diagnosis
Procedure
Surgeon (and note about presence during case)
Assistant(s)
Anesthesia
Operative Findings
Specimen(s)
Drains
Closure
Complications
Fluids Administered
EBL (Estimated Blood Loss)
Urine output
Case Classification:
Clean
Clean Contaminated
Contaminated
Dirty & Infected
Outcome Statement
Dictated by _____________________________________________________________________________ on Date________________
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