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  Identification  Name  -  Age  -  Handedness  -  Gender  -  Family/other contact person
● H &P Summary  Presentation  -  Symptoms  - Signs  -  Impairments  -  Treatment & results  
●  Pre-op test results  Imaging -  Physiologic -  Hematologic - Coag  - Chemistries  - Cultures
●  Diagnoses & Allergies  All current diagnoses including: anatomic, physiologic, pathologic, temporal, etiologic,  classification
●  Pre-op medications  Antibiotic -  Steroid -  Anticonvulsant -  Diuretic -  Concurrent diagnoses Rx
●  Consent  Options and potential consequences adequately explained and understood
●  Surgical goals  Specific anatomic changes sought - consequences local and remote of the intervention
●  Anatomic landmarks  Surface - Bone - Muscle - Dura - Vessels - Nerves - CSF spaces - Foramena  - Gyri - Sulci
●  Approach & positioning  Step-by-step outline including site & side, landmarks, maneuvers, intentions, strategies, risks
●  Specific risks  Focal - Remote - Neurologic - Vascular - Cardiac - Respiratory - Infectious - Skin - Urinary tract - etc
●  Resources needed  Instruments -  Imaging -  Lines, tubes, drains  - Ultrasonic aspirator -  Micro -   Image guidance -  Graft -  Prosthesis -  Electrophysiology  -  Photo  -  Path
●  Operative team  Surgeon - Assistant(s) - Observer - Nursing - Anesthesia - Other
● Specimen management  Frozen section - Permanent histology - Microbiology - Formalin fixed or not
●  Expected blood loss  
●  Post-operative monitoring  Electronic - Nursing -  MD -  Vital signs -  Neuro signs -  Spinal signs -  ICP - Hematology   Chemistry - Fluid balance - Nutrition - Comfort - Safety -  Progress/regression
●  Communication plan  With whom, where and when
●  Documentation  Dictated note - written chart note - drawing/diagram - photo - video
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