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The Breast Surgeon Note template by s10.ai is expertly crafted for breast surgeons to efficiently document patient consultations. It features comprehensive sections for subjective and objective findings, past medical history, family history, and a detailed assessment and plan for surgical concerns. This template is particularly beneficial for surgeons managing cases involving breast masses, prior surgeries, and familial cancer history. It ensures thorough documentation, supporting both pre-operative planning and post-operative care. Optimized for integration with s10.ai, an advanced AI medical scribe, this template streamlines the documentation process, enhancing patient care and clinical workflow efficiency.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
Subjective:The patient, a 45-year-old female, is here for a consultation regarding a noticeable lump in the right breast, which has been present for about three months. The lump has grown in size and occasionally causes pain. The patient mentions no factors that relieve the symptoms and has not previously sought treatment.Past Medical/Surgical History:- The patient underwent a lumpectomy on the left breast five years ago, with no post-surgical complications.Allergies:- The patient is allergic to penicillin, which results in a rash.Medications:- Currently using ibuprofen for pain relief.Family History:- Mother was diagnosed with breast cancer at age 50.Social History:- The patient does not smoke, drinks alcohol socially, and works as a school teacher. She resides with her husband and two children in a suburban area.Objective:- Vitals: Blood pressure 120/80 mmHg, heart rate 72 bpm, temperature 98.6°F.- Physical examination shows a 2 cm firm, non-mobile lump in the upper outer quadrant of the right breast. No axillary lymphadenopathy is observed.Assessment & Plan:1. Right breast mass- Assessment: The likely diagnosis is a benign breast tumor, but malignancy cannot be excluded without further tests.- Differential diagnosis includes fibroadenoma and breast carcinoma.- Planned investigations: Mammogram and ultrasound of the right breast, followed by a core needle biopsy.- Planned surgical treatment: Possible excisional biopsy based on biopsy results.- Pre-operative preparation: Patient advised to stop NSAIDs 7 days before surgery.- Post-operative care plan: Discussed expected 1-day hospital stay, pain management with acetaminophen, wound care instructions, and follow-up appointment in 1 week.- Relevant referrals: Referral to an oncologist for further evaluation if malignancy is confirmed.Additional Notes:- Patient education and informed consent: Discussed the procedure, potential risks, benefits, and alternatives. The patient expressed understanding and agreed to proceed with the planned investigations.- Instructions for emergency care: Advised to monitor for signs of infection or excessive bleeding post-procedure and to seek immediate care if these occur.- Addressed patient concerns about the impact of surgery on daily activities and reassured her about the recovery process.
Key advantages of using this template in clinical practice
Common questions about this template and its usage