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Upper airway bronchoscopic approach and diagnostic procedures
Published in Don Hayes, Kara D. Meister, Pediatric Bronchoscopy for Clinicians, 2023
Anesthesia for sleep endoscopy is controversial and the choice depends on the ability of the agent to be titrated to achieve the most representative sleep state. Deeper levels of sedation are associated with decreased muscle tone, airway collapsibility, and tendency toward atelectasis. A discussion between the anesthesiologist and the endoscopist about the anesthetic agents and administration techniques should be held prior to the patient being sedated.1 Documentation of the anesthetic choices in the operative report is helpful.
Sources of Medical Information
Published in Julie Dickinson, Anne Meyer, Karen J. Huff, Deborah A. Wipf, Elizabeth K. Zorn, Kathy G. Ferrell, Lisa Mancuso, Marjorie Berg Pugatch, Joanne Walker, Karen Wilkinson, Legal Nurse Consulting Principles and Practices, 2019
Patricia J. Bartzak, Deborah Enicke, Patricia Ann “Stormy” Green
Surgical procedures are performed in an operating suite. Other invasive procedures may take place in the radiology department, endoscopy unit, intensive care unit, or the pre-operative area. The provider who performed the surgery or procedure completes a procedure report, which must be completed within the period mandated by the facility’s policies and procedures. For surgical procedures, the surgeon completes an interim operative report to ensure skilled care in the post-operative period and transition to next level of care (The Joint Commission, 2018b).
Good Physician Writing is a Communication Skill
Published in John Gartland, Better Physician Writing and Speaking Skills, 2018
However, for most physicians the ability to write well is not a natural talent, and therefore it takes a dedicated effort and a lot of practice to become an effective physician writer. As often as possible physician writers would be well advised to follow the writing rule that stipulates “one sentence, one idea.” Putting too many details into one sentence makes it awkward and confusing for readers to follow. Consider the following sentence from a physician’s dictated operative report:
International assessment of interobserver reproducibility of flap delineation in head and neck carcinoma
Published in Acta Oncologica, 2022
Arnaud Beddok, Leslie Guzene, Alexandre Coutte, David Thomson, Sue S. Yom, Valentin Calugaru, Eivind Blais, Olivier Gilliot, Séverine Racadot, Yoann Pointreau, June Corry, Kenneth Jensen, Sandro Porceddu, Nazim Khalladi, Vianney Bastit, Audrey Lasne-Cardon, Pierre-Yves Marcy, Florent Carsuzaa, Christophe Nioche, Jean Bourhis, Julia Salleron, Juliette Thariat
The lack of reproducibility for FAMM flap delineation could be due to the complex visualization of the flap on postoperative imaging, including CT [19]. A postoperative MRI could possibly help the radiation oncologist to delineate the FAMM flap, especially the T1 and T2-weighted MR, and the CUBE enhanced fat-suppressed T1-weighted MR. This was however beyond the scope of the current study. It is important to remember that this flap is usually short, harvested in a plane deep to the facial artery by including the overlying part of the buccinator muscle along its length and part of the orbicularis oris in the area of the oral commissure [20]. The FAMM flap is rotated next to its native mucosal cheek area. It does not add any unusual tissue such as bone, thick muscle, or artificial material in the reconstructed area, which may have made it easier to identify on imaging. Therefore, even more than for other flaps, the operative report is necessary to accurately locate the flap site and its components based on their tissue densities, length and thickness after flap harvesting and reshaping. A standardized operative report should include precise information, already listed in the atlas [11].
Technical Tips: A Checklist for Responding to Intraoperative Neuromonitoring Changes
Published in The Neurodiagnostic Journal, 2019
The checklist also provided an unexpected benefit in documentation. In the paper copy of the checklist provided on each IONM machine, the technologist notated all the corrections and modifications that the team used (successfully or not) to improve the neurologic outcome for their documentation in the patient record and in the technologist’s notes for the patient’s chart. Having the information available in one document including further details about the other teams’ actions during monitoring changes, and providing this information to the surgeon at the end of the case, enables the surgeon to be quickly supplied with a comprehensive document of all remediation for the operative report.
Revision pediatric cochlear implantation in a large tertiary center since 1986
Published in Cochlear Implants International, 2020
Yann-Fuu Kou, Jacob B. Hunter, Joe Walter Kutz, Brandon Isaacson, Kenneth H. Lee
The University of Texas Southwestern Medical Center institutional review board approved this study. A retrospective chart review was performed on the first 834 CI surgeries performed in children under the age of 18 at a tertiary care pediatric hospital from 1986 to 2013. We collected basic demographic data (age, sex, race, laterality) from all subjects who also routinely underwent preoperative imaging with either computed tomography or magnetic resonance imaging. Cause of SNHL was recorded for all patients, with those subjects requiring revision surgery were categorized as: unknown etiology, meningitis, connexin 26 mutation, cochlear dysplasia, enlarged vestibular aqueduct, auditory neuropathy, CHARGE association, cytomegalovirus (CMV), and chromosomal abnormalities. The specific CI device was recorded for each patient, as well as the time between the initial surgery and identification of the CI failure. Indications for re-implantation surgery were categorized as: vendor recall, trauma, infection, cholesteatoma, facial nerve stimulation, and unknown. Of note, devices that were recalled by the vendor (implant company) were not automatically explanted. Only implants that failed or demonstrated decreased function were explanted and re-implanted with a new device. The indication for re-implantation to have been categorized as ‘vendor recall’ was failure of a recalled device with no other identifiable reasons for lost or decreased function. Re-implantation for devices that were recalled for concerns of compromised device integrity were all classified as hard failures. In addition, cases of trauma and loss of hermetic seal were considered hard failures. In the analysis, we classified cases where the failure was unknown as soft failures. Details regarding whether a complete insertion was accomplished was based on the operative report.