DATE AND TIME: [Date and time]
SURGEON: [Name]
ASSISTANT: [Name / None]
ANAESTHETIST: [Name]
OPERATION: Femoral Embolectomy (Right / Left)
ANAESTHETIC: General / regional / local anaesthesia
ANTIBIOTICS: [Drug and dose / Not indicated]
DVT PROPHYLAXIS: [Agent / mechanical / Not indicated]
URGENCY: Emergency — acute limb ischaemia
POSITION: Supine
INDICATION:
Acute [right / left] lower limb ischaemia secondary to embolic occlusion. [Onset, limb status: viable / threatened / irreversible].