Re: Operative Notes

From: Elrod, Darryl G MAJ 48 MDOS/SGOBO (Darryl.elrod@LAKENHEATH.AF.MIL)
Sat Feb 25 02:27:08 2006


Or course, preop diagnosis, postop diagnosis, procedures etc are all part of it. I just get a bit annoyed when I'm forced to dictate a specimen even when there isn't one, (I've been known to list the baby as my specimen from a c-section...it is something that is removed and something sent away) and a specific section for findings when they are already clearly spelled out.

But sooner or later I'm sure I'll adapt.

Glen

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D. Glen Elrod, Maj., USAF, MC

Obstetrician/Gynecologist

Chief of Obstetrics

48 MDOS/SGOBO

RAF Lakenheath, England

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From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of

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DoctorJoe@aol.com
Sent: Friday, February 24, 2006 1:03 PM
To: Multiple recipients of list OB-GYN-L
Subject: Re: Operative Notes

In a message dated 2/24/06 2:48:50 AM, Darryl.elrod@LAKENHEATH.AF.MIL writes:

I have always included that in the narrative part of the report. Apparently, now there is a rule that there has to be a separate 'findings' heading with something dictated there. I now dictate the findings there and then only reference that in the narrative section.

I always dictated with a PREOPERATIVE DIAGNOSIS and then a POSTOPERATIVE DIAGNOSIS section before the actual OPERATIVE NOTE.

Joe P.





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