PROCEDURAL NOTE
PATIENT: Lopez, Olga
AGE: 76 years
DATE: 11/05/2014
PATIENT DIAGNOSIS: Multiple skull lymphomas
PROCEDURE: Craniotomy converted to craniectomy of left anterior cranial base
ANESTHESIA: General endotracheal
The patient was placed in supine position on operating table and anesthesia was successfully administered. The patient was then prepped in the usual manner. An incision was made on the midline of the patient’s anterior cranial base and the surgeon dissected the epidermal layer to reveal the skull. Three .2 to .4cm lymphomas were then located and the skull bone was excised in one piece to remove the affected areas, leaving .1cm margins. Halfway through the procedure the patient’s blood pressure dropped, which was difficult to control for the remainder of the procedure. Due to the patient’s drop in blood pressure, the surgeon decided to convert the procedure to a craniectomy, therefore bone grafts were not placed. A drain was placed beneath the remaining skull base and the edges of the skin were then sutured back together using 4-0 vicryl sutures. A sterile dressing was placed on the excision site. The patient was then removed from endotracheal anesthesia and remained under physician supervision until her blood pressure stabilized. The patient was then taken to the recovery room and scheduled for a bone graft at a later date.
In the above procedural scenario, the anesthesiologist spent 30 minutes prepping and administering the anesthesia to the patient. The surgeon spent 2 hours 15 minutes performing the procedure and then another hour and a half was spent after the patient was removed from anesthesia and returned to post-operative recovery. The anesthesiologist supervised the patient in post-op recovery for an additional 30 minutes.
How much time should the anesthesiologist report for his service?
