Medical Transcription: Sections of an Operative Report

The Operative Report is part of the Big Four: the family of reports that comprise the core of medical transcription work. Here, step through each section of the report in detail, including section headings, formatting, and organization.

Physicians and assistants

The first section of an operative report states the date of the operation and spells out who should get credit (or blame) for the results. Many modern transcription platforms fill in the surgeon’s name automatically. Surgical assistants, and occasionally the anesthesiologist, also may be named here, and you’ll likely need to add those manually.

The current standard is to omit periods between letters in professional designations such as MD and PA, but some facilities still prefer they be included. Most lines in medical reports end in a period, but names are an exception. The result should look similar to this:

SURGEON
Ivana Kutzov, MD
FIRST ASSISTANT
Pansy Ford, PA-C
ANESTHESIOLOGIST
Gibbon Gass, MD

Preoperative and postoperative diagnoses

The pre- and postoperative diagnoses immediately follow the names of the surgical team members. If there’s a single diagnosis, don’t number it. List multiple diagnoses vertically as a numbered list. End each line with a period. Remember to expand any abbreviations or acronyms in the diagnoses section into their full form to comply with the general formatting guidelines described in Chapter 6.

PREOPERATIVE DIAGNOSIS
Menorrhagia.
POSTOPERATIVE DIAGNOSES
1. Menorrhagia.
2. Uterine fibroids.
3. Pelvic adhesions.

If the pre- and postoperative diagnoses are identical, the dictator may lump them together as “pre- and postoperative diagnoses.” You should still transcribe them as distinct sections. The quickest method is to copy the preoperative diagnoses list and insert it immediately following the first list. Change the second heading to Postoperative Diagnoses and you’re done.

In the preceding paragraph, note that pre- has a hyphen after it. When multiple suffixes (in this case pre- and post-) with the same root appear in a row (often with the word and between them), the proper punctuation is to append a hyphen to all but the last suffix. You’ll encounter this a lot with pre- and post-.

Procedure performed

This section will be titled Procedure Performed, Operation, Operative Procedure, or something similar. If there’s a single procedure, don’t number it. Otherwise, transcribe the procedures as a vertical numbered list. End each line with a period. This is another report section where abbreviations and acronyms should always be expanded. A procedure list should look like this:

OPERATIVE PROCEDURES
1. Right shoulder arthroscopy with subacromial decompression.
2. Arthroscopic acromioclavicular (AC) joint resection.

If the dictator uses a singular form of a heading, such as diagnosis or operation but lists multiple items beneath it, transcribe the heading in its plural format, such as diagnoses or operations.

Anesthesia

This section, usually quite brief, specifies the method of anesthesia used during the procedure. Anesthetics often are used in combination (for example, local with IV sedation). Occasionally, the anesthesiologist also will be named here. This section appears similar to the following:

ANESTHESIA
General endotracheal administered by Dr. Gassor.
ANESTHESIA: MAC.

The table lists the types of anesthesia you’ll hear dictated most often. Having an idea of which types of anesthesia are used for what can help you decipher difficult-to-understand dictation.

Commonly Dictated Anesthesia Terms
Type of Anesthesia Commonly Used in Surgeries For . . .
General, general endotracheal Any surgery where the surgeon wants the patient totally unconscious and unaware
Local Local numbing for minor procedures
Epidural Surgical procedures and pain relief from the chest downward, including childbirth and C-sections
Spinal Surgical procedures below the umbilicus
Interscalene block Shoulder, upper-arm, forearm
MAC, IV sedation Colonoscopy, upper endoscopy, and other uncomfortable procedures that don’t require general anesthesia
Bier block Arm below the elbow, leg below the knee

Indications for procedure

This section, sometimes titled simply Indications, gives a brief summary about why the patient is undergoing the operation. Some dictators include it and others don’t. It should be transcribed in paragraph format, like this:

The patient is a 37-year-old female who injured her right knee while playing hockey approximately 4 months ago. She continued to have pain despite exercise and anti-inflammatories, thus indicating the need for arthroscopy.

Findings

This section gives the surgeon’s observations regarding the anatomic structures visible during the operation. Surgical findings may be incorporated into the Description of Procedure section that comes next, but they’re often dictated as a separate section instead or in addition, like this:

FINDINGS
Extensive adhesions of omentum and somewhat the colon to the abdominal wall in the right abdomen from his prior open cholecystectomy. The tumor itself was about 4 cm in diameter. It was in the ascending colon just proximal to the hepatic flexure. There was some inflammatory change around it. There was no gross adenopathy. There was no gross evidence of metastatic disease.
FINDINGS: A type II SLAP lesion with instability of the biceps.
blog comments powered by Disqus
Advertisement

Inside Dummies.com