Re: Operative Notes

From: ainsron (ainsron@sbcglobal.net)
Tue Feb 28 09:02:33 2006


Yes. I always dictate the findings. It is one of the requirements that surveyors look for in dictated op notes and it has always made sense to me to write it in my postop note as well as dictate it.

Ronald E. Ainsworth, MD, FACOG

-----Original Message----- From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Garry E. Siegel, M.D. Sent: Thursday, February 23, 2006 6:56 PM To: Multiple recipients of list OB-GYN-L Subject: Gyn: Operative Notes

Do all of you put a section in your dictated operative notes describing the findings, or at least describe the findings in the text?

I have seen two patients recently--one had an open supracervical hysterectomy/unilateral S and O (other side already out), the other a unilateral S and O, and the op notes described what was done nicely, but not the findings, i.e. how large was the ovary being removed, was there adhesive disease or endometriosis, etc. They were not very helpful, frankly.

Garry

--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA




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