Procedure Note
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VASECTOMY

PRE-OP DIAGNOSIS: Desires Elective Sterilization
POST-OP DIAGNOSIS: Elective Sterilization Z30.2
PROCEDURE: Elective Bilateral Vasectomy - CPT 55250
ANESTHESIA: [checkbox value="Lidocaine 1% without epinephrine|Marcaine 0.5%|Sodium BiCarb buffering solution"]. Total amount used: [text size="5"]ml. [checkbox memo="check if multiple agents" name="multanesth" value=""][conditional field="multanesth" condition="(multanesth).is('')"][text size="50"][/conditional]
[checkbox name="supervision" value="Supervising Physician:"][conditional field="supervision" condition="(supervision).is('Supervising Physician:')"] Dr. [text size="20"]
[/conditional]
INDICATIONS:
-Patient desires elective sterilization.
-Confirmed that Patient was counseled regarding the risks, alternatives, and benefits of male sterilization by vasectomy.
-Confirmed that patient was informed of the risks of the procedure, including but not limited to failure of the procedure to produce sterility, the risks of bleeding, infection, chronic testicular pain, and injury to scrotal contents.
-Confirmed that all questions were answered in the pre-vasectomy counseling visit. No guarantees were given or implied.
-Verified that the consent form was signed prior to patient taking preprocedural medication(s).
-A time out was performed prior to the procedure and documented in a hardcopy form to be scanned into patient's record.

PHYSICAL EXAM:
Inspection/Palpation of the genitalia: [select memo="choose one" name="exam" value="|unremarkable|see below"][conditional field="exam" condition="(exam).is('unremarkable')"]
-no significant abnormalities or contraindications to performing the vasectomy in the outpatient clinic
-both testes normal without tenderness, masses, hydroceles, varicoceles, erythema or swelling.
-penile shaft normal, meatus normal without discharge
-anatomic landmarks were confirmed[/conditional][conditional field="exam" condition="(exam).is('see below')"]
[textarea memo="describe abnormalities/anomalies" memo_color="orange" memo_size="small"][/conditional]

PROCEDURE
-The patient was laid supine on the procedure table.
-He was prepped and draped in the usual fashion using [select value="Betadine/Iodine|Chlorhexidine"] and allowing proper dry time per manufacturer and infection control recommendations.
-After identifying the vasa bilaterally, the left vas was grasped using the three-finger technique.
-Using a 27g needle, a 1-2 cm wheal was made at the [select name="incisionsite" value="left scrotum|right scrotum|midline scrotal raphe"] 1 cm distal to the base of the penis with anesthetic agent to provide local skin anesthesia.
-The needle was then advanced through the wheal parallel/adjacent to the [select value="Left|Right|B/L"] Vas Deferens.
-After gentle aspiration, anesthetic agent was injected into the [select value="proximal perivas tissue|external spermatic fascia"] to achieve regional vasal block.

-The [select value="Left|Right"] Vas Deferens was maneuvered to the desired incision site, and [select value="no-scalpel technique with fine cured hemostat|fine-tip Bovie electrocautery|#15 blade scalpel|#11 blade scalpel"] was used to make a 1-2 cm incision.
-The soft tissue was then bluntly dissected with fine cured hemostats.
-The [select value="Left|Right"] Vas Deferens was grasped and elevated through the incision and exposed using vas fixing forceps. Perivas tissue was bluntly dissected away using [select value="|fine cured hemostats|fine-tip bovie electrocautery"].
-Once it was decided that sufficient perivas tissue had been dissected away and risk of superimposed vascular tissue over the vas deferens was low, a 1cm section of vas deferens was isolated using vas fixing forceps to grasp distal and proximal ends.
-[select value="Hemostats|Alice clamps"] were used to secure testicular and prostatic ends of vas deferens prior to transection.
-The 1cm segment of vas deferens was transected/excised using [select value="|#15 blade scalpel|#11 blade scalpel"] and this 1cm section was sent for pathologic examination/review.
-[select value="Electro|Thermal "]cautery was applied to [select value="1cm|0.5cm"] length of the lumen of [select value="|both prostatic & testicular ends|the prostatic end"] of the Vas Deferens until blanching occurred.
[checkbox memo="only check if applicable" memo_size="small" name="interposition" value="-Facial interposition achieved with figure of eight stitch"][conditional field="interposition" condition="(interposition).is('-Facial interposition achieved with figure of eight stitch')"] using [select value="5-0|4-0"] vicryl suture material.
[/conditional]-The area of remaining Vas Deferens and perivas tissue exposed through the incision was inspected thoroughly.
-[select name="hemostasis" value="Good hemostasis was noted|Gentle electrocautery applied to achieve good hemostasis|Suturing was required to achieve hemostasis"] before the remaining Vas Deferens was reduced back into the scrotum.
[conditional field="hemostasis" condition="(hemostasis).is('Suturing was required to achieve hemostasis')"]-[select value="5-0|4-0"] vicryl suturing material used.
[/conditional]-These procedural steps described were repeated on the [select value="Right|Left"] Vas Deferens[conditional field="incisionsite" condition="(incisionsite).is('midline scrotal raphe')"] using the previously created midline raphae incision[/conditional].
-[select name="EBL" value="Estimated blood loss was less than 2 ml.|Estimated blood loss was"][conditional field="EBL" condition="(EBL).is('Estimated blood loss was')"] [text size="3"]ml and [textarea memo="hemostatic actions taken and referral arrangements as applicable" memo_color="orange" memo_size="small"][/conditional][conditional field="EBL" condition="(EBL).is('Estimated blood loss was less than 2 ml.')"]
-For closure, scrotal fascia/skin was [select name="closure" value="allowed to close by secondary intention|closed with"][/conditional][conditional field="closure" condition="(closure).is('closed with')"] [select value="4-0|5-0"] [select value="Prolene|Nylon|Silk|Ethibond"] suture material[/conditional].[conditional field="EBL" condition="(EBL).is('Estimated blood loss was less than 2 ml.')"]
-Skin was dressed with sterile gauze.

-The patient tolerated the procedure well. No immediate complications noted.

-Patient was reminded of post-procedural instructions including: [checkbox value="physical limitations and work restrictions|using ice packs 20min on/off|use of scrotal support underwear (spandex/jock-strap)|avoiding contact with pets or kids for first 48-72hrs that might put patient at risk of accidental trauma and hematoma formation|picking up kit/instructions for semenanalysis from the lab|returning with semen sample to lab after 25 ejaculations AND after 13 weeks have elapsed"]

-Gave patient return precautions to include: worsening pain more than 24hrs after the procedure, rapid increase in the amount of swelling of scrotum over the course of a few hours, white pus draining from wounds, and development of fever.

-Patient left in stable condition. Followup plan: [textarea].[/conditional]
VASECTOMY

PRE-OP DIAGNOSIS: Desires Elective Sterilization
POST-OP DIAGNOSIS: Elective Sterilization Z30.2
PROCEDURE: Elective Bilateral Vasectomy - CPT 55250
ANESTHESIA: . Total amount used: ml. check if multiple agents

INDICATIONS:
-Patient desires elective sterilization.
-Confirmed that Patient was counseled regarding the risks, alternatives, and benefits of male sterilization by vasectomy.
-Confirmed that patient was informed of the risks of the procedure, including but not limited to failure of the procedure to produce sterility, the risks of bleeding, infection, chronic testicular pain, and injury to scrotal contents.
-Confirmed that all questions were answered in the pre-vasectomy counseling visit. No guarantees were given or implied.
-Verified that the consent form was signed prior to patient taking preprocedural medication(s).
-A time out was performed prior to the procedure and documented in a hardcopy form to be scanned into patient's record.

PHYSICAL EXAM:
Inspection/Palpation of the genitalia: choose one

PROCEDURE
-The patient was laid supine on the procedure table.
-He was prepped and draped in the usual fashion using and allowing proper dry time per manufacturer and infection control recommendations.
-After identifying the vasa bilaterally, the left vas was grasped using the three-finger technique.
-Using a 27g needle, a 1-2 cm wheal was made at the 1 cm distal to the base of the penis with anesthetic agent to provide local skin anesthesia.
-The needle was then advanced through the wheal parallel/adjacent to the Vas Deferens.
-After gentle aspiration, anesthetic agent was injected into the to achieve regional vasal block.

-The Vas Deferens was maneuvered to the desired incision site, and was used to make a 1-2 cm incision.
-The soft tissue was then bluntly dissected with fine cured hemostats.
-The Vas Deferens was grasped and elevated through the incision and exposed using vas fixing forceps. Perivas tissue was bluntly dissected away using .
-Once it was decided that sufficient perivas tissue had been dissected away and risk of superimposed vascular tissue over the vas deferens was low, a 1cm section of vas deferens was isolated using vas fixing forceps to grasp distal and proximal ends.
- were used to secure testicular and prostatic ends of vas deferens prior to transection.
-The 1cm segment of vas deferens was transected/excised using and this 1cm section was sent for pathologic examination/review.
-cautery was applied to length of the lumen of of the Vas Deferens until blanching occurred.
only check if applicable-The area of remaining Vas Deferens and perivas tissue exposed through the incision was inspected thoroughly.
- before the remaining Vas Deferens was reduced back into the scrotum.
-These procedural steps described were repeated on the Vas Deferens.
-.
Result - Copy and paste this output: