Shock Wave Lithotripsy Operative Note

Patient name: [Full name]; Date of birth: [DOB]; MRN: [MRN]

Date of procedure: [Date]

Facility/location: [Facility or site]

Procedure performed: [Extracorporeal Shock Wave Lithotripsy (ESWL), laterality, anatomic site]

Surgeon/proceduralist: [Name, credentials]

Anesthesia type: [General / MAC / Sedation / Local]

Preoperative diagnosis: [Diagnosis with laterality and anatomic location]

Postoperative diagnosis: [Diagnosis with laterality and anatomic location] (Typically same as preoperative unless findings differ.)

Indication

[Clinical indication and presenting symptoms] [Stone burden summary] [Imaging summary: modality, date, stone size in mm, location, radiopacity] [Rationale for ESWL over alternatives] (2–4 sentences. Include Hounsfield units and skin-to-stone distance only if documented; omit if not available.)

Consent and Verification

[Statement confirming informed consent obtained and time-out completed with correct patient, procedure, and laterality verified] (If documented elsewhere in EHR, a brief reference statement is sufficient.)

Pre-Procedure

Positioning: [Supine / Prone] [Positioning modifications if any]

Antibiotic prophylaxis: [Agent, dose, indication] (Include only if administered; document indication such as stent manipulation, infected stone, or bacteriuria.)

Pre-existing devices: [Ureteral stent present / Nephrostomy tube present / None]

Anesthesia and Tolerance

[Anesthesia type and adequacy] [Patient tolerance] [Issues affecting targeting: movement, respiratory excursion, need for additional analgesia] (Keep brief unless complications occurred.)

Stone Characterization

• Stone 1: [Laterality]; [Anatomic location: kidney (pelvis/upper/mid/lower calyx) or ureter (proximal/mid/distal)]; [Size in mm]; [Radiographic appearance: radiopaque / radiolucent] (If location was uncertain intraoperatively, document the uncertainty explicitly.)
• (Include additional bullets for each stone treated.)

ESWL Technical Parameters

• Lithotripter: [Manufacturer and model]
• Localization method: [Fluoroscopy / Ultrasound / Combined]; [How targeting was maintained]
• Coupling: [Adequate / Issues encountered and corrective actions]
• Total shocks delivered: [Number]
• Shock rate: [Shocks per minute]
• Energy settings: [Starting energy]; [Stepwise ramping: yes / no]; [Maximum energy achieved]
• Targeting quality: [Stone in focal zone / Limitations: respiration, bowel gas, body habitus, skeletal overlap]
• Intra-procedure fragmentation assessment: [How fragmentation was monitored]
• Fluoroscopy time/dose: [Values if recorded] (Omit if not available.)

Findings and Results

Fragmentation outcome: [Excellent / Good / Fair / Poor / None] — [Clarification of fragmentation appearance] (If fragmentation could not be reliably assessed, state explicitly.)

Stone visibility/tracking: [Consistently visible / Intermittently visible / Poor visibility]

Immediate observations: [Hematuria, skin changes, or other notable findings / None]

Treatment limitation: [Reason for abort/limitation]; [Shocks delivered before stopping]; [Next-step plan] (Include only if treatment was aborted or limited.)

Additional Procedures

(Include only if performed; otherwise omit this section.)

• Ureteral stent placement: [Indication]; [Size/length]; [Laterality]; [Confirmation method]; [Retrieval string: left in place / not left]
• Other procedure: [Procedure name]; [Indication]; [Key details]

Complications

[None / Description of complication and management] (Document arrhythmia, inability to localize, severe pain, suspected hematoma, and actions taken.)

Disposition

[Patient condition: stable, pain controlled]; [Destination: PACU / Recovery / Discharge home]

Post-Procedure Plan

• Medications: [Analgesic plan]; [Alpha-blocker/MET if prescribed]; [Antibiotics if indicated with reason]
• Fragment passage: [Urine strainer instructions]
• Follow-up imaging: [Modality based on stone radiopacity] in [Timeframe, e.g., 4 weeks]; [Who will arrange if not yet scheduled]
• Follow-up visit: [Clinic appointment timing]
• Return precautions: Fever, uncontrolled pain, persistent vomiting, inability to void, anuria, worsening hematuria, signs of obstruction

Signature

[Proceduralist name, credentials]

[Date and time of signing]