Operative Report Format

IDENTIFY yourself clearly (first and last name), spell patient’s first and last name, and give the patient medical record number.

• Date of Surgery
• Operating Surgeon
  • FOR RESIDENTS: Please state “I am dictating for…” including physician’s first and last name. 
• First Assistant, Second Assistant, etc.
• Postoperative Diagnosis (DO NOT use abbreviations in diagnoses)
• Operation Performed – include biopsies (DO NOT use abbreviations in procedures or operations)
• Anesthesia
• Incision
• Findings, in detail
• Procedure, in detail
• Closure
• Condition of patient at end of operation
• Prognosis
• Specimens removed
• Estimated blood loss
• Drains or packs
• Needle and sponge counts
• Classification of wound

NOTE: Please note in dictation: Attending surgeon was present during the critical portion of the procedure and/or entire procedure.