How to dictate Operative Reports?

The quality of transcripts transcribed by medical transcriptionist is dependent on how the medical records are dictated by physicians.

There are multiple parts of operative reports and it should be dictated in the following order

1. Always dictate Patient’s Name (first and last) in the beginning of report. And if its spelled out ensures no mistake.

2. Second most important information is the Patient’s HUN # (Medical Record Number)

3. And then followed by Date of Admission and Date of Procedure

4. Its always good to dictate Primary Physician/Surgeon to avoid any ambiguity

5. Assistant(s) if any

6. Description of Findings

7. Preoperative Diagnosis

8. Postoperative Diagnosis

9. Anesthesia (Not required, but strongly recommended)

10. Description of Procedure(s)

11. Specimen(s) removed