The Transperineal MRI Fusion Biopsy template by s10.ai is an all-encompassing documentation resource tailored for urologists conducting prostate biopsies. This template meticulously records critical elements such as patient demographics, preoperative and postoperative diagnoses, procedural nuances, and operative specifics. It is especially beneficial for documenting MRI fusion-guided biopsies, ensuring precise and comprehensive capture of the procedure and patient consent. Urologists aiming to optimize their documentation workflow while ensuring detailed and accurate records will find this template indispensable. Designed for seamless integration with s10.ai, the AI medical scribe, it significantly boosts efficiency and precision in clinical environments.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
DATE OF SURGERY: 11/01/2024PATIENT: John A. SmithDOB: 03/15/1965MEDICAL RECORD NUMBER: 123456789SURGEON:s10.aiPREOPERATIVE DIAGNOSIS:Elevated PSAPOSTOPERATIVE DIAGNOSIS:SamePROCEDURE:Transperineal prostate biopsy with MRI fusionANESTHESIA: General.INTRAVENOUS FLUIDS: 500 mL of crystalloid.ESTIMATED BLOOD LOSS: 0 mL.DRAINS:NoneSPECIMENS:20 cores to pathologyCOMPLICATIONS: None.INDICATIONS: John Smith, a 59-year-old male, with elevated PSA levels and a family history of prostate cancer.After a discussion of risks, benefits, pros, cons, side effects, and alternatives, he opted to undergo prostate biopsy under sedation. I informed him aside from anesthesia complications (if an anesthetic is used), regarding trans rectal ultrasound biopsy of the prostate I discussed possible negative outcomes which may include, but are not limited to: excessive bleeding from the anus especially in patients with hemorrhoids, blood clots in the urine, blood in the ejaculate, urinary retention, and urinary tract infection or urosepsis rarely requiring hospitalization. I also reviewed the detailed prostate biopsy handout in the clinic with the patient and provided him a copy to take home. We have previously discussed controversies related to prostate cancer screening. I discussed the above issues with him as well as other issues related to prostate biopsy.OPERATIVE PROCEDURE IN DETAIL:After proper informed consent was obtained, the patient was brought to the endoscopy suite. Antibiotics were not necessary. He was positioned in yellowfin stirrups in lithotomy and universal protocol time-out was called using a standardized checklist.The scrotum was elevated anteriorly and taped out of the perineum. The perineum was then prepped with ChloraPrep. A perineal skin puncture site was identified at the site halfway between the lateral aspect of the prostate gland in the medial aspect of the prostate gland on both the right and left side. A local skin block with 1% lidocaine was then used to anesthetize either side.Using a precision point access needle system the puncture site on the right was stabilized with a 15 gauge needle and a long spinal needle was used to puncture the subcutaneous tissue provide local anesthesia with 1% lidocaine. The block consisted of anesthetizing the subcutaneous tissue and apically blocked just proximal to the GU diaphragm and levator muscle bilaterally.The prostate was co-registered with the software fusion platform by performing a sweep and lining up the images.The prostate gland was not resized because of accurate measurements on MRI. Using biplanar guidance the prostate was then sampled with the following (2 cores RPM and RPL, 2 Cores LPM, LPL, and 2 cores RAM, RAL, LAM, LAL, RB, LB, 20 total). These were then sent off the field for pathologic analysis.The rectal probe was then removed. The puncture sites of the skin were dressed with fluff dressing. The patient was sent to recovery.I was present throughout the entire procedure. The patient was awakened from anesthesia and transferred to the recovery room in stable and satisfactory condition.s10.ai11/01/2024
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