A reader suggested that after finishing my long-winded description of an operation, it would be interesting to see how it all would look in a typical operative report ("op note.") I like it!
It is said -- and I happen to agree wholeheartedly -- that op notes ought to be dictated immediately, else the content stales likes a bagel. I was pretty fanatical about doing so; nothing bugs me more (OK, lots of things bug me more) than being told by medical records that I'm delinquent on a dictation. ANY dictation; but particularly op reports, because I always did them instantly. Usually I'd write with a flourish that I HAD dictated and give the date. It was not entirely rare that they insisted it wasn't anywhere, so I'd go to my office and find the copy that I'd already received, and tell them if they'd send me a self-addressed stamped envelope and a dime, I'd copy and send it. But that's neither here nor there. (Usually, though, it WAS there.)
To me a good op note is succinct and stripped of irrelevant data. Surgeons read lots of them, because we like to know what went on inside someone who's fallen into our care after prior surgery. It's amazing. Some people tell you their shoe size, what soap they used on their hands, every sort of instrument they used. "Metzenbaum scissors were used to cut... Sutures were tagged with Kelley clamps..." Who cares? I want to know what was found, what was done in enough detail to predict what I'm likely to find. "The patient was brought into the operating room... (check that.... the operating suite!)" As opposed to what? Operating in the hall?
I sit at a desk in recovery; or if the patient is taking a while to awaken, I grab the phone in the OR and bend it into the corridor, punch in the numbers for the dictation system, the campus, an op note. There are numbers for start/stop, repeat, back up, etc; I never learned them. Blast on through fast as I think someone can transcribe, giving spelling when necessary, and punctuation. I heard a lecture once given by a guy who'd just finished dictating a bunch of charts. He kept saying to the audience things like "Hello comma I'm Dr Jones period. I'd like to talk to you today comma and I'll leave time at the end for questions period.... Sorry exclamation point."
This is Doctor Sidney Schwab dictating operative report on Blah (bee ell ay aich) Blah (bee ell ay aich).
Date 5/14/07 to 6/1/07.
Assistant: Joanie.
Preop diagnosis: diverticulitis.
Postop diagnosis: same.
Operation: Sigmoid Colectomy.
Indication: recurring episodes of diverticulitis.
Findings: The mid-sigmoid was indurated and thickened and contained multiple diverticula. It was stuck laterally to the pelvic sidewall. A couple of loops of small bowel were stuck to it medially. There was no evidence of perforation or abscess. The uterus and ovaries were normal.
Description: After induction of general anesthesia the abdomen was prepped with one-percent iodine and draped sterilely. A lower midline incision was made and the peritoneal cavity was entered without difficulty. Wound edges were covered with moist laps and a retractor was placed. The sigmoid was mobilized off the pelvic sidewall with blunt and sharp dissection, and the small bowel was mobilized sharply without enterotomy. A portion of tissue remaining on the pelvic wall was removed sharply and sent for frozen section. Bleeding was controlled with cautery. Packs were placed to expose the operative field. Sites for division were selected and cleared of fat. The peritoneal reflection was incised laterally and within the pelvis to achieve adequate mobility. Mesentery was divided using clips and vicryl ties. The field was covered with betadine-soaked pads. Bowel clamps were placed and the bowel was divided sharply and the specimen was removed. Bowel ends were wiped with betadine. An open end-to-end anastomosis was accomplished using interrupted 4-0 silk and running 3-0 vicryl. There was excellent circulation to both sides of the anastomosis, absence of tension, and wide patency to palpation. Mesentery was closed with running 3-0 vicryl. Packs were removed and the field was copiously irrigated with dilute betadine solution. After final inspection for bleeding, peritoneum was closed with 0-vicryl, wound was further irrigated with betadine solution, infiltrated with quarter percent marcaine plain. [note: I used to use it with epinephrine, which lasts a bit longer; but I use so much that I don't want any confusion: if the patient has tachycardia, I want to know it's not from the local] Fascia was closed with number one vicryl running. Skin was closed with a few interrupted subcuticular 4-0 vicryl followed by steri-strips. Sterile bandage was applied and the patient was brought to the recovery room in stable condition.
Complications: none
Estimated blood loss: negligible
Specimen to pathology: sigmoid colon and biopsy of pelvic sidewall. Endofdictationthankyou.
18 comments:
Dr. Schwab, if this operation were done in a teaching hospital, and certain parts, most or all of the operation were performed by a resident, would this have to be indicated in the report? If not, how does the resident get credit or recognition for his contribution?
And thank you so much for such an enlightening series, made so easy for the layperson to follow.
I'll be waiting for your post on adhesions.
Interesting blurb on op reports, since I saw quite a number of examples of such as a HIT student and got to know what was really "necessary" and what was superfluous information irrelevant to the content that would actually be coded for reimbursement. Some docs are better than others at it, or so I heard from the experienced HIM people from my internships. I would think dictation would be better than handwriting, however.
May all of your estimated blood loss be negligible.
why not a laparoscopic approach?
buck: for all the reasons I've mentioned in previous posts: I see no advantage whatsoever when I can do the operation via a small incision, taking 40 or so minutes, having the patient go home in two days. Not to mention I happen to enjoy sewing bowel (which, if it were worse in some way, would not be justified.) By comparison to lap colectomy, my approach saves thousands of dollars; I know of no lap series in which the average patient goes home any faster, returns to work any quicker. I've done three colon resections in a four-hour block: I doubt that can be said by surgeons doing it laparoscopically.
A running anastomosis with 3-0 or 4-0 nylon would work just fine, and would save you a little time. And, what's with all the Betadine? It's injurious to tissue, even at the one per cent or less concentration at which it's effective.
anon: all I can say is my wound infection rate was so low as to be nearly non-existent; likewise leaks. I'm too lazy to look them up, but I know of studies that have confirmed efficacy of dilute betadine in wound irrigation. If it's injurious in the lab, I had no evidence of it in practice. I realize my anecdotal experience isn't exactly scientific. But I found what I did to be highly effective. The sum total of it was that in the brief period when a local large insurance company collected data on total costs per operation type and distributed to surgeons, my costs for colectomy were among the least in the entire state; I can't recall if I was first or second: it was one or the other for colon, and the other or one for mastectomy, as it turns out. I only used betadine for open bowel cases. It might well be true that water alone, or other antibiotic solution would have done as well, but I had no reason to find out! I'm just a country doc, after all.
Your comments on the essential elements of an op note are right on target. On occasion, I have done surgical quality reviews for a cooperative group and I have seen some horrendously bad op notes. I once reviewed a case that included a one paragraph op note (from a well-known teaching hospital, no less) that "described" a total laryngectomy and radical neck dissection...not a single finding was mentioned, although I learned that it described a six hour procedure.
(Blogsnooper here -- I've given up trying to post under that name, just won't work -- hence I shall identify myself among all the other 'anonymouses'!)
Love your writing. The links are most interesting too -- sometimes they are the real thing and sometimes a hilarious gag, you never can be sure which. ("Dr. Scwab's links are like a box o' choklits, ya never know what you're gonna get")
Bruce: when I was in training there was an emeritus professor who still came around once in a while. Very famous guy, had a nerve named after him. I used to see his op notes. They went like this:
"A radical mastectomy was performed in the usual manner. H. Glenn Bell."
anon: finally!! I enjoy my "gag" links. No one has ever commented on them, so I'm glad there's at least one person out there who likes them, too.
You forgot to answer my qeustion. :'-(
(corr)*question*
emily: you get "credit" for those cases in which you are first assistant. In applying for certification, you list your cases you did, and, separately, those in which you were first assistant. If it's a case for which the attending is primary surgeon, even if he/she lets you do parts, that's how it's listed. When the resident does the case -- ie when it's a "clinic" case, as it were -- he/she is listed as the primary surgeon, and the attending as the assistant. Usually.
"...ergo propter op." Hahahaha. You could do a post on weird postop complaints that patients blame on the surgery. "Doc! could you give me some Viagra? ever since you took my colon out, the second time just ain't what it used to be!"
Hmmm...I wonder if "all sponge, needle and instrument counts were 'reported' to be correct."? This "all important phrase" to be included in the op note is near and dear to my heart
W8Tn: I never dictated that. My reason is, I thought it obvious, just like I never dictated that I washed my hands and put on gloves. No operation is finished until that phrase is uttered; it's written in the record as well, in the nursing notes. And, as you may be implying, the saying of it doesn't make it so. Whereas no surgeon would finish until s/he's told the counts are correct, and none would ignore an incorrect count, it has happened -- and still does -- that a count is announced as correct, only to find later that something was left in. Rare. But real.
*Sigh* Dr. Schwab,
I read the whole thing at once, one through ten. How very, very cool. Scientifically gripping, and also elucidating (the humanity of the surgical team). Thanks for opening yourself up to critique like this for the sake of sharing. That cannot be easy - semi-retired or no.
Great blog doc! - I have to agree with you on the pour betadine- I use the hand assist for lap colons and used to have wound infections at the umbilicus where the hand port was placed - Betadine works great! - I also paint incisions with it and it "anecdotally" works great in my practice. Thanks.
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