Medical Transcription 12 Lecture Slides.pdf

Medical Correspondance & Report II

1. Medical Correspondance& Report II
Week 13: Operative Reports
MEDICAL TRANSCRIPTION
DR EBENEZER ODURO ANTIRI

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•Operative reports are the most complex dictations you’ll transcribe. 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.
Operative Reports
M E D I C A L C O R R E S P O N D A N C E & R E P O R T I I

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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:
1. Preoperative and postoperative diagnoses
2. Names of physicians and assistants involved in the procedure
3. Title of the procedure performed
4. Type of anesthesia used
5. Reason the procedure was performed
6. Operative findings
7. 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
8. Any complications or unexpected developments encountered
9. The patient’s condition at the end of the procedure and where he was taken
afterward
Overview
M E D I C A L C O R R E S P O N D A N C E & R E P O R T I I

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•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.
Overview
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•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
Physicians and Assistants
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•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.
•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.
Preoperative and Postoperative Diagnoses
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•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.
Procedure Performed
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•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:
ANAESTHESIA
General endotracheal administered by Dr. Gassor.
ANESTHESIA: MAC.
Anaesthesia
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•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.
Indications for Procedure
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•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 omentumand 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.
Findings
M E D I C A L C O R R E S P O N D A N C E & R E P O R T I I

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•This section is the meat of an Operative report.
•Common alternative headings include Procedure in Detail and Operative
Technique.
•It provides a blow-by-blow account of the operative procedure from start to finish.
•Some Operative reports consist of only preoperative diagnoses, postoperative
diagnoses, and this section.
•The description can run from a half-dozen sentences to multiple pages, depending
on the complexity of the operation and individual dictator habits.
•The procedure description is transcribed in paragraph format.
•For short Operative reports, a single paragraph is sufficient.
•If a dictator does specify paragraph breaks, transcribe them as dictated, unless
they’re blatantly awkward or incorrect.
•For example, some dictators have a habit of specifying “new paragraph” after every
sentence, which results in a very fragmented report.
•In such cases, use your judgment to create paragraph breaks in appropriate places.
•Paragraphs should be separated by a blank line.
Description of Procedure
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•If a surgeon dictates a novella-length Procedure in Detail with no paragraph breaks,
insert them as appropriate.
•It’s often easiest to type the entire section and then go back and look for paragraph
opportunities while proofreading.
•A new paragraph should be inserted when the topic changes. Logical points include
the following:
1.Between a description of preparation and the beginning of the procedure, if the
preparation is more than a sentence long.
2.Between the description of the dictator’s initial inspection of the relevant anatomy
and when she starts to actually do something to it.
3.In a multipart procedure, insert a paragraph break when the operation proceeds
from one stage to another. A good clue is a phrase such as “Attention was then
turned to the . . .” or “Next, . . .”
4.Just before the description of wound closing and bandaging.
Description of Procedure
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•Here is a sample surgery description with appropriate paragraph breaks:
DESCRIPTION OF PROCEDURE
The patient was brought to the OR and was given Ancef 1 g intravenous antibiotics. Bier block
anesthesia was performed. The limb was then prepped and draped in a sterile fashion.
With that completed, a palmar-based incision was made for an open carpal tunnel release. The
transverse carpal ligament was incised with a complete distal and proximal incision. The median
nerve was identified and protected at all times. With the procedure complete, irrigation was
performed.
A simple closure was performed with 3-0 nylon, and a bulky Bunnell-type dressing was applied.
The tourniquet was deflated. The sponge, needle, and instrument counts were found to be
correct. The patient was awakened and taken to the recovery room in stable condition.
Description of Procedure
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•The Disposition section records where the patient went after leaving the operating
room. Sometimes it also includes instructions or plans for the immediate
postoperative period.
•DISPOSITON: The patient was transported to the recovery room in stable condition.
•DISPOSITION The patient will be discharged to home with instructions to elevate
the extremity; maintain the dressing clean, dry, and intact; and follow up in the office
in 72 hours for a wound check.
Disposition
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•The previous headings are the ones most commonly included in an
Operative report.
•The sections 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
Additional Headings
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•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.
Complications
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•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.
Tourniquet time
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•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
Estimated blood loss
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•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 Hemovacdrain.
Drains
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•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
Hardware and implants
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•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.
Hardware and implants
M E D I C A L C O R R E S P O N D A N C E & R E P O R T I I

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•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
Specimens
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•Nearly every surgery wraps up with wound closure.
•When a dictator describes how they sutured something, they may mention
suture size, suture material, and the suturing method, usually in that order.
•Suture sizes range from 11-0 (smallest) to 7 (largest).
•Dictators pronounce the zero as “oh,” so “one oh nylon sutures” should be
transcribed as 1-0 nylon sutures. If the dictator says “number one oh nylon
sutures,” place a # sign where the dictator says “number”:
Dictated: number one oh nylon sutures
Transcribed: #1-0 nylon sutures
Sewing Up the Case
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•The type of suture material usually follows right after the size. It may be
stated as a trade/brand name, such as “Prolene” or using a generic term,
such as “polypropylene.”
•There are many, many types of suture material.
•Here are the ones you’ll encounter most often: absorbable, fast-absorbable,
Prolene(polypropylene), nylon, Ethibond, Ethicon, Ethilon, chromic, catgut,
silk, Vicryl, Mersiline(polyester), Monocryl, Dacron, Tevdek, PDS, steel,
Nurolon.
Sewing Up the Case
M E D I C A L C O R R E S P O N D A N C E & R E P O R T I I

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•Next up is the manner in which the sutures are deployed, frequently
dictated as “in a something fashion” or “using something technique.”
•Here are words commonly used in this section:
•Simple, interrupted, running, horizontal or vertical mattress, subcuticular,
subcutaneous, locking or interlocking, over-and-over, tension, retention,
figure-of-eight, purse-string, Halsted, Lembert
•Often several of them will be strung together, as in: using interrupted
vertical mattress technique
Sewing Up the Case
M E D I C A L C O R R E S P O N D A N C E & R E P O R T I I

26. Any questions?
Thanks!
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