How to Transcribe OP Reports

Doctors dictate operative reports after surgeries or other procedures that are considered high-risk. They must do this immediately so that the record can be placed in the patient's medical chart. Most dictation involves verbal recordings that are transcribed into written document format before the patient is moved to the next level of care. The doctor has to dictate enough information regarding the medical procedure to produce a quality transcription of the operative report. This will aid in providing managed care for the patient throughout the hospital stay.

Instructions

• 1

  Play the doctor's dictated procedure from the audio recording. Pause the tape when necessary as you write down the pertinent information. Begin by writing down basic information that states the date, location where the procedure took place and the patient's name.

• 2

  Include the basic preoperative diagnosis, postoperative information (if different from preoperative) and the procedure. Finish writing the basic information list at the top of the report by noting the surgeon's name, any assistants who helped with the procedure, the type of anesthesia and the anesthesiologist's name. Conclude the list by writing the name of the doctor who dictated the operative report.

• 3

  Provide dictation details of the patient in summary format after the basic information listing. This will include the patient's medical history. Transcribe the doctor's medical knowledge supporting the diagnosis, treatment, preoperative course of action and the results. The end of the operative report should contain any additional information the doctor dictated concerning followup treatment for the patient's continued care.