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Operative Report Example 5 (Page 1)

Operative Report

Name: Melanie Black
Hospital No.: 000036

Address:


Clinic or Floor:
Surgery Date: 09/27/91

Race: Black
Age: 27
Sex: Female

Surgeon: Rex Glover, MD
Assistant: Henry Backas, MD

Time Operation Started: 11:52 am
Ended: 12:30 pm

Pre-operative Diagnosis: Right breast tumor

Operative Diagnosis: Doubtful malig. of R breast tumor

Operation Performed: Excision of R breast tumor

Procedure in Detail:

The tumor of the right breast just to the right of the nipple was excised and sent to the laboratory for frozen section. The incision was closed. First report on frozen section was equivocal; will await results of paraffin section.

Sponge Count _______________
Drains _______________

Dictated by: Rex Glover, MD
Surgeon: Rex Glover, MD

Continued on next page.