How to Write an OP Report

Surgeons are required to dictate or write an operative report for each surgery they perform. Most of the time, medical transcriptionists, who have special training in the language of medicine, transcribe these reports. Operative reports document the reasons for the surgery and the surgical procedure. They act as a witness or protection for the surgeon, if the patient were to have problems after surgery or if he sued the doctor. This is one of the main reasons it is a good idea to be as specific as possible when you write an operative report.

Instructions

• 1

  Type the patient's name and medical record number. Include the patient's date of birth. Each hospital's requirements are different.

• 2

  State the type of operation you performed. This begins on the line after the patient's name and medical record number. Leave a blank line in between each section. For example, an eyelid lift would be written like this: "Title of Operation: Blepharoplasty." If this was done to improve the patient's looks, you may include "aesthetic" as part of the operation title, as in "Title of Operation: Aesthetic blepharoplasty." Aesthetic surgeries are usually considered elective.

• 3

  Begin a new paragraph, leaving a blank line in between the new one and the last one. State the preoperative diagnosis. It should be written like this: "Preoperative Diagnosis: Congenital deformity of the eyelids" or whatever the diagnosis is.

• 4

  Begin a new paragraph, leaving a blank line in between the new one and the last one. State the postoperative diagnosis. Write it like this: "Postoperative Diagnosis: Congenital deformity of the eyelids." The postoperative diagnosis is often the same as the preoperative diagnosis.

• 5

  Begin a new paragraph, leaving a blank line in between the new one and the last one. Title the next section: "Operative Indications." In this section, briefly tell what brought the patient to see the doctor, the patient's name, age and sex, how long the problem has been a concern and other relevant information.

• 6

  Begin a new paragraph. You are still writing in the "Operative Indications" section. Write the surgical solution and reasons for surgery in this new paragraph. Also, include the list of risks that you discussed with the patient. Be sure to include a sentence that the patient understands the risks and wishes to proceed with the surgery --- if that is the case.

• 7

  Begin a new section titled "Procedure in Detail." Leave a blank line in between the last section and this new one. In this section, discuss every step you completed during the operation, from sedation through sending the patient to the recovery room. Be explicit and very specific. Include the specific tools you used and how you used them. Mention any problems that the patient had during surgery and what the surgical team did to resolve the problems. If the surgery was unremarkable, say so in this section. Include the sponge, needle and instrument count to show that all of the equipment and supplies were accounted for at the end of the surgery.

• 8

  Conclude the report with a statement about the end of the surgery. For instance, you may say, "The patient's breathing tube was removed, he was awakened from anesthesia and then moved to the recovery room in stable condition for observation." Proofread and edit your report.