PATCHARADA AMATYAKUL, M.D.

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

FACULTY OF MEDICINE

NARESUAN UNIVERSITY

Objectives

How is it important ?

Grammar and vocabulary

Common format

Example of common operative

procedures for M.D.

Assignments

Operative notes

A document produced by a surgeon or other

physician(s) who have participated in a surgical

intervention, which contains a detailed account of

the findings, the procedure used, the specimens

removed, the preoperative and postoperative

diagnoses, and names of the primary performing

surgeon and any assistants.

How is it important ?

One of the most challenging hospital report

Record what you have done

Know each step of the procedure

More familiar with human anatomy

Acts as a witness / protection for surgeons

A part of the audit system (HA)

Therefore, it must be absolutely correct

Basic anatomy

Instruments

Suture materials

Steps of the operations

Medical terminology

Basic grammar

Past tense : past simple

Subject + Verb 2

Passive voice

Subject + was/were + Verb 3

Finite verb

Non-finite verb (to + verb 1)

•Abdominal wall was opened layer by layer.

•Gas was injected to create pnuemoperitoneum

Noun

Adjective: Modifiers of nouns

Adverb

: Modifiers of adjective

: Modifiers of verb/ adverb

• Yellow pus was identified at the cervical os.

• The cyst wall was accidentally ruptured.

Adjective: Must follow verb to be

Color: red, brown, yellow, green

Size: big, small

Side: left, right

Shape: round, irregular

Suffixes: -al, -ic, -ive, -ful, -ous,

-able, -ed

• A smooth surface, white mass with 5x6 cm in

diameter protruded from uterine fundus.

• The mass at the rectal mucosa was red.

Noun and verb agreement

Single and plural

• The right globe was enucleated.

• The left and the right globes were enucleated.

• All the suspected endometriotic lesions were

cauterized with bipolar cautery.

• The right fallopian tube was removed.

• The other tube was normal.

Another, other, others

Another: uses with single (in general)

Other + pleural(s) (in general)

The other + single (specific, only one

left)

The other + pleural(s) (specific)

Name of patient, hospital number

Date on operation

Time start, end, operative time

Surgeon and assistants

Preoperative diagnosis

Postoperative diagnosis

Operation / procedure

Anesthesiologist

Anesthetic method

: GA, regional, local, IV sedation

Position

Incision

Operative findings

Normal

Abnormal

Picture

Procedure in detail

Pathological specimen

Complication / how to resolve

Estimated blood loss

Instrument / Prosthesis

Packing (very important)

Place the drain

Suturing materials

Number of stitches

Special monitoring if needed

Signature of surgeon or assistant

Operation / Procedure

Emergency, urgent, elective surgery

Exploratory laparotomy for …………..

Laparoscopic ….. / Hysteroscopic …./ Arthroscopic…..

Vaginal………..

Excision of ………

Incision and drainage (I&D) of ……

Curettage : Fractional, evacuation, dilatation and

curettage

Position

Supine

Prone

Dorsal lithotomy

Lateral decubitus

Trendelenburg

Sitting

Fowler

Incision

Midline, longitudinal

Paramedian

Circumferential

Infraumbilical

Pfannenstiel , suprapubic

T-shape, Inverted T

Grid, Lanz, McBurney

Suture materials and suturing

Suture materials

Silk, catgut, chromic catgut, nylon, Vicryl,

monofilament (Monocryl), Dexon

Suture techniques

Continuous locking / non-locking

Interrupted stitches / Simple

Mattress

Subcuticular

Continuous stitch interrupted stitch

Continuous locking or blanket stitch

Purse string

http://residentnet.com/sutures.htm#pursestring

Procedure in detail

Write down step by step

Which instruments/techniques were used

If performed both sides, start with one

side and follow by the other

Place or pack something

Bleeding was checked and stopped

Operation / Procedure

Appendectomy, cholecystectomy

Cesarean section

Hysterectomy

Unilater, bilateral salpingo-oophorectomy

Tubal resection, Tubal sterilization

Open reduction and internal fixation (ORIF)

Open

Approach, explore, examine, identify

Clamp, cut, ligate, remove, break down,

dissect (blunt /sharp), drainage

Paint, mark

Insert, place

Suture, close

Bleeding was checked and stopped.

Easiest words: found, done, perform

Uneventfully

Accidentally: tear, rupture, cut through

Thoroughly

Circumferentially sutured

Abdominal was opened layer by layer

….. was inserted/ placed at……..

…..was clamped, cut(ted), and sutured

by ....material no. ….., continuously

Sutured with interrupted stitches

Bleeding was thoroughly checked and

stopped by cautery/suturing with….

Drain was placed at………

Tissue was removed for pathological

examination

Example of operative Note

Assignment

Students are divided into 5 group

Write a complete operative note for each procedure

Acute appendectomy

Ruptured tubal pregnancy

Incisional and drainage of breast abscess

Evacuation and curettage of abortion

Tubal resection

Presentation and discussion (next week)

References

How to Write an OP Report | eHow.com

http://www.ehow.com/how_8587683_write-op-

report.html#ixzz28gvrms6N

http://www.utmb.edu/surgery/clerks/surgdocu.htm

http://mtguide.blogspot.com/2005/04/operative-notes-training-workshop.html