Operative Note (Septoplasty/Turbinate Reduction)

Operative Note: Septoplasty [with / without] Inferior Turbinate Reduction

(Structured fields through Findings serve as the immediate post-procedure summary for PACU handoff. Document only what was observed and performed. Do not infer laterality, adequacy of hemostasis, or absence of complications unless explicitly verified. Omit sections that do not apply or were not assessed unless explicit documentation of absence is required by local policy.)

Date of Surgery: [Date]

Start Time / End Time: [Start time / End time]

Location: [Facility name and OR number]

Surgeon: [Primary surgeon name and credentials]

Assistant(s): [Assistant name(s) and role(s)] (Omit if none.)

Preoperative Diagnosis

• [Clinical diagnoses prompting surgical intervention] (List each diagnosis on its own line; include laterality if applicable.)

Postoperative Diagnosis

• [Confirmed diagnoses based on intraoperative findings] (If diagnosis changed intraoperatively, briefly state why.)

Procedures Performed

• [Procedure name and laterality] (List each procedure on its own line, e.g., Septoplasty; Bilateral inferior turbinate reduction with submucosal microdebrider and outfracture.)

Anesthesia

[Anesthesia type: [general / MAC / local with sedation]]; [Airway management details if applicable]

Findings

• Septal deviation: [Location: anterior/caudal, mid, posterior], [Direction of deviation], [Presence and location of spurs], [Nasal valve involvement]
• Inferior turbinates: [Severity of hypertrophy], [Characteristics: mucosal vs bony vs both]
• Additional findings: [Other relevant intraoperative findings such as synechiae, polyps, mucosal condition, unexpected pathology] (Omit if none.)

Indications

[Brief summary of functional symptoms], [Key anatomic contributors identified on examination], [Relevant prior medical management and response], [Rationale for surgical intervention] (Single concise paragraph.)

Procedure Details

Positioning and preparation: [Patient positioning], [Skin and mucosal preparation], [Draping]

Access and local infiltration: [Incision type and location], [Local anesthetic agent(s) with concentration and volume], [Vasoconstrictor and concentration], [Topical decongestants used]

Septoplasty: [Elevation of mucoperichondrial and mucoperiosteal flaps and integrity], [Cartilage and bony work performed: removed / scored / repositioned], [Preservation of dorsal and caudal struts for structural support], [Septal reconstruction techniques if used], [Closure method including quilting sutures for hematoma prevention]

Inferior turbinate reduction: [Technique(s): [submucosal microdebrider / radiofrequency ablation / cautery / partial resection / outfracture / combination]], [Laterality and extent], [Energy parameters if applicable], [Mucosal preservation], [Outfracture details if performed] (Omit if turbinate reduction not performed.)

Hemostasis: [Methods used: vasoconstriction, cautery type, topical agents], [Source of bleeding if notable], [Additional interventions taken]

End-of-case assessment: [Final septal position], [Turbinate position], [Airway patency], [Final hemostasis check], [Integrity of septal mucosa bilaterally; document any tears and management]

Splints, Packing, and Hemostatic Materials

• [Device or material type], [Location], [Fixation method], [Expected timing and setting for removal]

(If none placed, omit this section or state "None" per institutional preference.)

Specimens

• [Specimen description], [Source], [Destination]

(Omit if no specimens were sent unless policy requires explicit documentation.)

Estimated Blood Loss

[Numeric estimate in mL]

Complications

[Complication(s) encountered and management] (If none occurred after deliberate assessment, state "None.")

Disposition

[Patient condition at case end and destination]

Postoperative Plan

• Pain management: [Analgesic regimen]
• Antibiotics: [Agent, duration, and rationale] (Omit if not prescribed.)
• Nasal care: [Saline irrigations, topical ointment, humidification instructions]
• Activity restrictions: [Restrictions: avoid nose blowing, straining, heavy lifting]
• Splint/packing removal: [Timing and setting]
• Follow-up: [Timing and purpose]
• Return precautions: [Brisk bleeding not controlled with pressure and head elevation], [Fever], [Severe unilateral nasal pain or swelling concerning for septal hematoma], [Inability to tolerate oral intake]