Debridement of Wound Transcription Sample Report

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Wound dehiscence secondary to infection.

POSTOPERATIVE DIAGNOSIS: Wound dehiscence secondary to infection.

OPERATION PERFORMED: Debridement of wound with closure of fascia.

SURGEON: John Doe, MD

ASSISTANT: None.

ANESTHESIA: General endotracheal.

ANESTHESIOLOGIST: Jane Doe, MD

FLUIDS: 800 mL of crystalloid.

DRAINS: #7 Blake to peritoneal cavity.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: Approximately less than 200 mL.

DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed on the operating table in the supine position. General endotracheal anesthesia was performed. A Foley catheter was inserted using the aseptic technique. The patient’s abdomen was prepped and draped using the aseptic technique.

Attention was then turned to the patient’s incision. The edges of subcutaneous fat were excised using electrocautery. There was good healthy bleeding tissue noted. Edges of the fascia on each side were then incised using electrocautery. There was healthy bleeding tissue noted. Cultures of aerobic and anaerobic were taken of the wound. The wound was then irrigated out with saline, hydrogen peroxide half-and-half solution. A #7 Blake drain was introduced through a stab wound and placed in a subfascial level in the peritoneal cavity. This was sutured to the skin using 2-0 silk. The midline fascia was then approximated from the upper portion of the wound to the mid portion and then from the lower portion up with #1 Prolene running continuous suture.

The wound was then irrigated out with sterile water. Good hemostasis was obtained. The wound was then packed with Kerlix, normal saline drenched gauze. Sterile 4 x 4s, ABD, and tape were applied. A central line was placed. The patient was then extubated and transported to the recovery room in stable and satisfactory condition. Postoperative instructions, including signs to watch for, as well as followup instructions were provided to the patient and family.


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