The Operative Report: Additional Headings

Medical transcriptionists often transcribe an Operative Report. The sections of an Operative Report may be dictated in a different order or use alternative heading wording. Depending on the type of operation performed and dictator and facility preference, a report may include additional headings.

Complications

This heading is used to call attention to any complications or unexpected circumstances encountered during the surgery. Often this information is included in the Details of Procedure section, but it may also be given its own heading. It’s almost always as follows:

COMPLICATIONS
None.

Tourniquet time

A tourniquet is sometimes used during a procedure to prevent blood flow to the area being operated on. In such cases, the amount of time the tourniquet was in place is usually specified.

TOURNIQUET TIME
16 minutes.

Estimated blood loss

This heading specifies how much bleeding occurred during the procedure. Usually it simply says “minimal,” but occasionally it’s more specific.

ESTIMATED BLOOD LOSS
Minimal.
ESTIMATED BLOOD LOSS: Less than 5 mL

Drains

At the conclusion of surgery, a tube may be placed to permit fluids to drain from a wound. When this is done, it will be mentioned in the procedure details or under a separate heading, like this:

DRAINS
One 1/8-inch Hemovac drain.

Hardware and implants

Operations that involve inserting something into the patient’s body and leaving it there will detail exactly what that something was. A pacemaker may be placed or an intraocular lens inserted.

Orthopedic operations frequently involve placement of enough screws and miscellaneous parts to stock a small hardware store. Items such as these are described in detail in the Operative report, either within the procedure description or under a separate heading, as in the following:

HARDWARE
Biomet mini-balance femoral stem, size 10; a Biomet metal-on-metal acetabular shell, size 58; with a 52 standard-size femoral head.
IMPLANT
Alcon Laboratories model MC50BD, 25.0 diopter lens.

Specimens

When body tissue is removed from a patient, it’s often sent for pathological examination. It may be an entire organ, such as a patient’s gallbladder, or some other tissue such as a tumor or cyst. The removed tissue is called a specimen, and it will be listed in the operative report, like this:

SPECIMENS
Bilateral palatine tonsils.
SPECIMEN: Appendix sent to Pathology
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