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.
