An operative report is dictated by the surgeon immediately after the procedure, detailing who did what to whom using what materials and methods. Operation reports also include dictations that surgeons or their assistants complete after operative procedures. Typically there is a brief written operative note and a more detailed operative report that is dictated by the attending surgeon in the chart. Medical transcription service providers can convert these dictated records into accurate transcripts.
The dictated operative note is an integral component of patients’ medical records. Good surgical practice emphasizes the need for clear operative notes for every operative procedure done. Any error in dictation made by the surgeon can lead to errors in transcripts and thus in EHRs. Hospital payments are also facilitated by accurate coding that is ascertained from patient notes including the operation note.
A clear dictation should describe the operative indications and findings and detail the steps of the procedure performed. Though dictating operative notes seems to be straightforward, it may happen that surgeons fail to include certain crucial information.
What Do Operative Reports Include?
Immediately after surgery, a record of the operation should be made including the following details.
- The names of the operating surgeon(s), assistant and theater anesthetist, the name of the consultant responsible
- The diagnosis made and the procedure performed
- Description of the findings
- Details of tissue removed, altered or added
- Details of serial numbers of prosthetics used
- Details of sutures used
- An accurate description of any difficulties or complications encountered and how these were overcome
- Immediate post-operative instructions
- The surgeon’s signature
The record should also contain information relating to anesthesia. Follow-up notes should be sufficiently detailed, which allows other doctors to assess the care of the patient at any time.
Surgeons Cannot Delay Operative Notes Dictation
If an operation is conducted, then the surgeon is responsible for dictating the operative report of the patient, describing in brief the details of the surgery. This report should be entered in the medical report immediately after the procedure.
If there is any delay in entering the reports, then an operative progress note should be entered in the medical record immediately after surgery to provide pertinent information for anyone required to attend to the patient. Surgeons should make sure that such an operative progress note contains at least minimum comparable operative report information such as the name of the primary surgeon and assistants, procedures performed, estimated blood loss, specimens removed, and post operative diagnosis.
In case the assistant surgeon is dictating the op note to bill for the surgery as primary surgeon, he/she must at least sign the operative report, attesting that the information in the report is accurate. Without this confirmation, things may lead to potential malpractice if something goes wrong.
Also, if the surgeon accompanies the patient from the operating room to the next unit or area of care, the operative note or progress note can be dictated in that unit or area of care.
Within the operating room, surgical reporting best practices are key to reducing post-operative complications and preventing operative report errors. Most general surgery residents (92%) report that they use at least one method to improve their dictations. Surgeons can improve their dictating skills by considering these tips –
- Dictate soon after the procedure, as the information will be fresh in your mind
- Speak at a reasonable speed. Volume issues usually involve a dictator who whispers, possibly because of confidentiality concerns.
- Choose a silent, quiet area. Always state your name and the name of the patient you are documenting care for.
- Organize reports before dictating. With unorganized reports, you are likely to leave something out, especially if they are interrupted.
A poorly dictated report requires greater attention and more time from transcriptionists, which increases the turnaround time as well. Consider outsourcing medical transcription tasks to an experienced company to avoid any documentation quality issues.