How to Minimize Errors When Dictating Operative Reports A poorly dictated operative report requires much more attention to transcribe. Outsource to a reliable medical transcription company to obtain error-free transcription service.
For healthcare providers such as surgeons, operative records are important for providing better treatment plan and ensure quality of care and patient safety. Operative reports serve as a document that records all the steps that were taken to complete the surgery without intended injury. These records are also important for defending a complaint or at the time of clinical negligence. Medical transcription services convert dictated operative reports into accurate transcripts with utmost accuracy. A dictated operative note is a clear record of all operative procedures and discusses the steps of the surgery in a chronological manner. Though operative reports are simple and straightforward, the chances of error are also high.
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Operative reports include:
Names of the operating surgeon(s), assistant and theater anesthetist, the name of the consultant responsible
Diagnosis made and the procedure performed
Description of the findings
Details about the tissue removed, altered or added
Details of serial numbers of prosthetics used
Details of sutures used
Accurate description of any difficulties or complications and how these were resolved
Immediate post-operative instructions
Surgeon’s signature
Operative reports also contain information about anesthesia and a follow-up note so that it becomes easier for doctors to assess the health of the patient. Dictating Operative Notes After the operation, the surgeons dictate operative report of the patient. The details of the surgery are briefly described and entered into the medical report immediately after the procedure. If there is any delay in entering the reports, then an operative progress note should be entered in the medical record immediately after surgery to provide pertinent information for anyone required to attend to the patient. Some of the best practices to ensure accuracy of operative reports are:
Speak at a reasonable speed for clarity. If a dictator whispers, possibly because of confidentiality concerns, it can cause volume issues.
Make sure to dictate soon after the procedure, so that the information will be fresh in your mind and it is easier to dictate.
Choose a silent, quiet area for dictating. Always state your name and the name of the patient you are documenting care for.
Organize reports before dictating will help you to dictate the procedure easily. With unorganized reports, you are likely to leave something out, especially if you are interrupted.
www.medicaltranscriptionservicecompany.com
918-221-7801
A poorly dictated operative report requires much more attention to transcribe. Outsource to a reliable medical transcription service to obtain error-free data with utmost accuracy according to your specific needs.
www.medicaltranscriptionservicecompany.com
918-221-7801