Generated Narrative: Procedure example-procedure

status: Completed

category: Surgical procedure

code: Operations on chest wall, pleura, mediastinum, and diaphragm

​subject: Patient/f92c383f-68de-46c1-8cde-970efa2d0f15

​encounter: Encounter/5579c35d-97af-463a-b4d7-df2d9e3dc267

performed: 2022-06-28 15:30:00+0800 --> 2022-06-28 18:00:00+0800

​recorder: PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba

​asserter: PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f

performer

function: Accident and emergency doctor

​actor: PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f

​onBehalfOf: Organization/11-05040012

performer

function: House officer

​actor: PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba

​onBehalfOf: Organization/11-05060009

​location: Location/8d988a14-4e08-4b57-a6d2-323218dcb76e

bodySite: Left thorax structure

outcome: Successful

complication: Complication 1, Complication 2

note: <div xmlns="http://www.w3.org/1999/xhtml">Procedure: Left chest tube insertion. Indication: Left lung hemothorax post MVA - Explained to patient procedure indication and complication. Patient understood and agreed - Positioned patient in a lying supine position with left arm above the head - Placed the patient on the cardiac monitor, pulse oximetry and supplemental oxygen - 2 large 16G bore cannula secured - Safety triangle landmark identified, cleaned and draped - Chest tube 22fr prepared and clamped with Kelly clamp - LA 10ml given around incision area - 3cm incision done between 4th and 5th rib intercostal space, mid axillary line - Kelly clamp used to bluntly dissect the underlying subcutaneous tissue muscle until left lung pleura reached - Index finger inserted into incision and used to sweep inside left chest cavity - chests tube size 22fr inserted with index finger guidance and chest tube connected to functioning underwater seal - incision site cleaned and chest tube secured with Prolene 1 purse-string suture.</div> (By PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba @2022-06-28 18:00:00+0800), <div xmlns="http://www.w3.org/1999/xhtml">Keep left chest tube in secured monitor VS every 30m, keep BP &gt; 120/90 Continue NP 3L/min Provide adequate analgesia Send for repeat chest PA once patient more conscious Trace CT brain preliminary report Update surgical team on finding, push for admission once patient return from X-ray</div> (By PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f @2022-06-28 18:10:00+0800)

usedCode: Silk suture, Forceps, Cannula, tube AND/OR catheter