l1ttle_0ne
Guru
This is the first time I've come across this. So I'm wanting other's opinion. Our physician has a medical student he supervised. He did a very short note, and the medical student did a very detailed note. Am I able to use the medical students dictation in addition to my physicians dictation since he supervised her?? This is not a teaching school, and this is the first time any of our physicians has done this. Any help you can provide would be great!! Thank you.
This is my doctor's note.
I have personally seen and examined this patient.
I supervised **** (Medical student) in the assessment of, and synthesis of the plan for, this patient.
I formulated the essential elements of the surgical plan with ****.
I discussed the pertinent risks, benefits and alternatives with the patient and her daughter and feel it appropriate to offer a laparoscopic cholecystectomy to be performed tomorrow morning if the patient is medically clear/stable.
We had a discussion regarding this plan including:
Procedure:
Laparoscopic cholecystectomy with cholangiogram, possible conversion to an open cholecystectomy
Alternatives:
Continued cholecystitis, possible (albeit remotely so) biliary pancreatitis and its risks (pain, possible death), possible choledocholithiasis and its risks (cholangitis, jaundice).
Benefits:
Treatment of underlying cause of pain and restoration of normal diet.
Risks (Including, but not limited to):
Bleeding with a remote possibility of transfusion, injury to the extrahepatic biliary tree (ranging from leak to stricture to complete disruption), retained stone in common duct
Complications (Including, but not limited to):
Organ damage, continued pain, possible fatty intolerance.
After a discussion of the above, the patient gives verbal consent to the procedure. A separate written consent will be obtained.
This is my doctor's note.
I have personally seen and examined this patient.
I supervised **** (Medical student) in the assessment of, and synthesis of the plan for, this patient.
I formulated the essential elements of the surgical plan with ****.
I discussed the pertinent risks, benefits and alternatives with the patient and her daughter and feel it appropriate to offer a laparoscopic cholecystectomy to be performed tomorrow morning if the patient is medically clear/stable.
We had a discussion regarding this plan including:
Procedure:
Laparoscopic cholecystectomy with cholangiogram, possible conversion to an open cholecystectomy
Alternatives:
Continued cholecystitis, possible (albeit remotely so) biliary pancreatitis and its risks (pain, possible death), possible choledocholithiasis and its risks (cholangitis, jaundice).
Benefits:
Treatment of underlying cause of pain and restoration of normal diet.
Risks (Including, but not limited to):
Bleeding with a remote possibility of transfusion, injury to the extrahepatic biliary tree (ranging from leak to stricture to complete disruption), retained stone in common duct
Complications (Including, but not limited to):
Organ damage, continued pain, possible fatty intolerance.
After a discussion of the above, the patient gives verbal consent to the procedure. A separate written consent will be obtained.
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