How I usually write an operative record

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
  • Incision
  • Intraoperative evaluation
  • Main operative procedure (excision with about 3-mm margin)
  • Hemostasis
  • Correct sponge count (I did not use needle, if I did, I will include needle count)
  • Wound repair and closure
  • Dressing

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.)

operative_technique_rj_15sept22

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