For Tulane:
DICTATION
5049883488
user ID #
1
33#
MRN
2
Dr *** dictating on behalf of Dr _________
Location
Date
Attending
Assistant surgeon
Preop diagnosis
Post op diagnosis
Procedure performed
EBL
Fluid
Specimens
Drains
Implants
Anesthesia
Findings
Radiology findings if any
Indication
Technique
Attending Present
Disposition
Everyone you’ve been doing a good job with op notes and it’s much appreciated. To continue to do well and prevent issues moving forward a few reminders.
1. For TURBTs please dictate size if effects coding and billing <2cm, 2-5cm, >5cm
PCNL also needs stone burden size <2 or >2cm
2. If doing URS HLL SBE - need to say flexible nephroscopy if up in the kidney on Thomas op notes. Please do this and don’t forget
3. For findings, put important info, Hemostatic? The measures of the corpora or urethra on a prosthetics case, number of vessels on a kidney. Watertight anastomosis, if using X-ray or US - hydro as seen on your retrograde? Cystic components on US, Doppler signal present…
4. Brief need to be in as the first thing you do post op and then put in your orders
5. Minimize use of acronyms. Don’t write TURP, please write out Transurethral resection of prostate — when other people look at op notes this saves them time.
**************Dr. Castle likes all of the important stuff (in particular “findings”) towards the top of the note before EBL, complications, Drains, tubes, etc. He’s mentioned this to me before and I think it’s reasonable since he can just quickly pull up a note and read the notable parts of the case without scrolling.
Also, Castle likes a “fluoroscopic findings” separate from “findings.”************