How I usually write an operative record which also reflects how I usually do the operation.
I place a primary preoperative and postoperative diagnoses.
I indicate what operative procedure was done.
I use drawing and illustration liberally for the operative findings and incision, not narrative description.
I place operative findings which are consistent with the operative diagnosis. In this example, discrete, well-defined border, fibrous on cut-section which are patterns for a fibrodenoma postoperative diagnosis.
I place the total amount of lidocaine infiltrated.
I include an intraoperative evaluation.
I place the procedures chronologically which are reflective of a usual operation:
- Local anesthetic infiltration
- Intraoperative evaluation
- Main operative procedure (excision with about 3-mm margin)
- Correct sponge count (I did not use needle, if I did, I will include needle count)
- Wound repair and closure
I include details if necessary such as type of suture used for wound repair and closure.
In some operative records, I may be very detailed. For examples:
- Drawing for the planned incision
- Prepping using alcohol or other antiseptic solution
- Anesthetic infiltration – subcutaneous then dermal along the planned incision
- Excision using electrosurgical equipment or blunt or sharp dissection using knife
- Hemostasis using electrosurgical equipment, sutures, or just pressure
- Count which usually includes sponge count, needle count and instrument count (as indicated)
- Wound repair (several or one layer; subcutaneous and dermal layer and subcuticular layer; types of suture used; simple interrupted; continuous; with reinforcement etc.)