Medical Transcription: Overview of Operative Reports

By Anne Martinez from Medical Transcription For Dummies

Operative reports are the most complex dictations in medical transcription. The third member of the “Big Four,” operative reports give a blow-by-blow account of a surgical procedure.

Any time one human being cuts open another and starts tinkering with her insides, it’s important to record precisely what was done, down to the last detail.

Certain operations are more common than others, and you’ll come to know them very well. By the time you’ve transcribed your sixth appendectomy, you’ll know the steps in such detail that it’ll seem possible you could perform one yourself.

If you’re ever stranded on a desert island and a companion develops appendicitis, just whip out your Swiss Army knife (hopefully, it’s sharp) and perform an appendectomy on the spot, saving his life. From then on, he’ll have to collect all the firewood and do the dishes, too.

Here is an overview of all the sections of an Operative report that you’re likely to find.

Operations aren’t just performed in hospitals; they’re also done in outpatient surgical centers and specialty clinics. An operative report is dictated immediately afterward, detailing who did what to whom using what materials and methods. A full operative report will include the following:

Preoperative and postoperative diagnoses
Names of physicians and assistants involved in the procedure
Title of the procedure performed
Type of anesthesia used
Reason the procedure was performed
Operative findings
A step-by-step narrative description of the procedure, including instruments used, specimens or tissues removed, any hardware or devices inserted, and wound closure and bandaging details
Any complications or unexpected developments encountered
The patient’s condition at the end of the procedure and where he was taken afterward

Operative reports cover all these topics, but the level of detail varies substantially based on the complexity of the procedure. Some Operative reports break out each topic with a specific heading; others consist of pre- and postoperative diagnoses, procedure name, and one long narrative encompassing everything else. You should transcribe the report exactly as dictated. Don’t insert additional headings or otherwise attempt to organize the report for clarity.

The majority of the examples in this chapter comply with heading and layout styles recommended in The Book of Style for Medical Transcription, 3rd Edition, by AHDI. A few stray from the BOS to demonstrate other common layouts you’re likely to encounter, such as a heading and data appearing on the same line rather than on separate lines.

When transcribing, you should always format reports and headings as specified by the account you’re working on, regardless of what standards may otherwise apply.

If a surgeon performs a particular operation frequently, she’ll often dictate large portions of it virtually identically every time. You can take advantage of this by creating shortcuts for those parts in your word expander software.

When the dictator starts a known section, you can whip out entire paragraphs with a few keystrokes. A word or phrase may change here or there, so be sure to adjust what you auto-inserted to exactly match the current report.