ABOUT: Particularly when just starting residency, dictating efficient and concise operative notes can be somewhat daunting.  We have compiled a list of common dictation examples to get you started.  Please also refer to our Surgical Video Atlas, Podcast, and 3D Temporal Bone Atlas for related content. Remember, operative notes carry significant medicolegal implications and it is your responsibility to document accurate and clear notes that reflect the specific details of your procedure. These are only examples and all dictations must be adapted to the particular encounter.

In addition to the describing the surgical narrative, most operative notes include these additional entries, but this may vary according to specific institutional preferences:

PREOPERATIVE DIAGNOSIS: ___
POSTOPERATIVE DIAGNOSIS: ___
PROCEDURE: ___
SURGEON: ___
ASSISTANT: ___
ANESTHESIA: ___ (e.g. GETA, general mask, local)
ESTIMATED BLOOD LOSS: ___
SPECIMENS: ___
INDICATION: ___
KEY FINDINGS: ___
COMPLICATIONS: ___

LARYNGOLOGY TABLE OF CONTENTS

1. Flexible Laryngoscopy

2. Awake Per Oral Vocal Cord Injection

3. Awake Transcervical Vocal Cord Injection

4. Awake KTP LASER Ablation of True Vocal Cord lesion

5. Microdirect Laryngoscopy with Vocal Cord Injection

6. Gore-Tex Type 1 Thyroplasty

7. Montgomery Type 1 Thyroplasty

8. Netterville Type 1 Thyroplasty

9. Microdirect Laryngoscopy with LASER

10. Subglottic Stenosis LASER with Jet Vent

11. Microdirect Laryngoscopy with Zenker’s Diverticulotomy

DICTATION OF EVENTS: In order to evaluate the chief complaint, laryngoscopy with distal chip technology was performed as a separate identifiable procedure.  ___% lidocaine with phenylephrine was instilled into the right and left nares. The flexible scope was passed along the floor of the ___ nasal passage. The entire upper aerodigestive tract was closely examined, specifically the nasopharynx, oropharynx including base of tongue and vallecula, and hypopharynx.  The larynx was examined, specifically the supraglottis, true vocal folds, and subglottis.  Vocal fold adduction and abduction were assessed.  The true vocal folds, arytenoids, and interarytenoid spaces were closely visualized to confirm presence or absence of erythema, edema, or structural lesions.  Pertinent findings included ___. The scope was removed. The patient tolerated the procedure well. This marked the end of the procedure.  All procedural pauses were observed and standard procedural protocols and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The patient was seated in an upright position for transoral awake injection laryngoplasty. Lidocaine ___% with phenylephrine was instilled into the right and left nares. A flexible distal chip scope was placed intranasally, and ___ cc of ___% lidocaine was used to topically anesthetize the larynx, epiglottis, and base of tongue.  The ___ was mixed in the usual fashion and injected into the ___ true vocal fold via per oral approach using a long curved needle.  A total of ___ cc of ___ was injected and filled the vocal fold well.  The patient had no breathing difficulties at the end of this case and tolerated the procedure well. This marked the end of the procedure. The patient was transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure. 

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The patient was seated in an upright position for awake transcervical injection laryngoplasty. Lidocaine ___% with phenylephrine was instilled into the right and left nares.  A flexible distal chip scope was placed intranasally, and ___ cc of ___% lidocaine was used to topically anesthetize the larynx. The neck was then injected with ___ cc of ___% lidocaine in the skin.  The FEES scope was removed, and the distal chip flexible laryngoscope was used to evaluate the true vocal folds and confirm the immobility.  The scope was then placed just into the laryngeal inlet, which allowed for good visualization of the infraglottic space. A needle was passed through the cricothyroid space and tracked up nicely into the ___ true vocal fold.  ___ cc of ___ was then injected into this area. This filled the true vocal fold nicely with good bulk.  The scope was removed.  The patient had no breathing difficulties at the end of this case and tolerated the procedure well. This marked the end of the procedure. The patient was transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure. 

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The Fire Risk Assessment was rated at ___. The patient was seated in an upright position for awake LASER ablation of a ___ true vocal cord lesion. Lidocaine ___% with phenylephrine was instilled into the right and left nares.  A flexible distal chip scope was placed intranasally, and ___ cc of ___% lidocaine was used to topically anesthetize the larynx, epiglottis, and base of tongue. Next, the flexible ___ scope with working channel was passed through the ___ naris to the level of the larynx. The KTP LASER was set at ___ watts with a ___-millisecond pulse width and ___ pulses per second. The glass fiber of the LASER was then placed through the working channel and used to ablate this abnormal tissue along the ___. In total, ___ joules were used. The patient had no breathing difficulties at the end of this case and tolerated the procedure well. This marked the end of the procedure. The patient was transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service using a ___.0 endotracheal tube, the table was turned and the patient was prepped and draped in the usual fashion for microdirect laryngoscopy. Upper and lower dentition were protected with ___ mouth guards. The ___ laryngoscope was introduced and suspended, allowing for good visualization of the larynx. Pictures were taken with 0 degree and 70 degree Hopkins rod telescopes. ___ injection material was prepared according to manufacturer specifications. The injection needle was inserted at the arcuate line in the ___ true vocal fold, just anterior and lateral to the vocal process.  A total of ___ cc of material was injected.  This provided good bulk to the infraglottis up to the glottis.  There was an over injection of approximately ___%. Once this was accomplished, pictures were again taken with 0 degree and 70 degree Hopkins rod telescopes. The laryngoscope and mouth guards were removed. This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number and placed in the supine beach chair position.  A light MAC was administered by the anesthesia service. A flexible laryngoscope was suspended above the head to permit good visualization and confirmation of the vocal fold motion deficit.  A ___ cm horizontal neck incision was then marked and injected with ___% lidocaine with ___ epinephrine.  The patient was prepped and draped in the usual fashion for type 1 thyroplasty. An incision was made along a natural horizontal skin crease measuring ___ cm in length. This was taken down through the platysma and subplatysmal flaps were elevated.  The midline raphe was clearly seen and split, allowing for good visualization of the thyroid cartilage.  A ___ blade was then used to elevate the tissue off the thyroid cartilage, specifically the lower border of the thyroid cartilage, and allowing for the inferior tubercle to be visualized.  Measurements were made of the height of the thyroid cartilage midline which was found to be ___ mm.  A mark was made at ___ mm, which was the halfway point in the midline thyroid cartilage. Another mark of ___ mm was made up from the area just posterior to the inferior tubercle.  A line was drawn corresponding to the superior edge of the true vocal fold.  Next, a window was created with an anterior aspect of the window ___ mm back from midline. The window measured ___ mm in length and ___ mm in height leaving an inferior cartilage strut.  This was drilled out using a ___ diamond drill. Next, the inner thyroid perichondrium was removed, and a small pocket was created posteriorly and anteriorly using an elevator.  Palpation posteriorly of the vocal process through the window was performed.  Next, the Gore-Tex implant was inserted in an accordion fashion, carefully stacked together.  The Gore-Tex was ___ mm in width and 0.___ mm in thickness.  A total of ___ cm in length was inserted pushing against the vocal fold with the remainder filling in the small window.  The voice was tested to assess the best location and amount of implant.  ___ suture was used to crisscross over the Gore-Tex to secure it in place along the outer thyroid cartilage.  The area was then irrigated thoroughly.  Hemostasis was achieved.  The midline raphe was closed with ___-0 ___ suture.  A ___ drain was placed and secured.  Platysmal flaps and subcutaneous tissue were closed with ___-0 ___ suture. The skin was then closed with ___. The patient had no breathing difficulties at the end of this case and tolerated the procedure well. This marked the end of the procedure. The patient was transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number and placed in the supine beach chair position.  A light MAC was administered by the anesthesia service. A flexible laryngoscope was suspended above the head to permit good visualization and confirmation of the vocal fold motion deficit.  A ___ cm horizontal neck incision was then marked and injected with ___% lidocaine with ___ epinephrine.  The patient was prepped and draped in the usual fashion for type 1 thyroplasty. An incision was made along a natural horizontal skin crease measuring ___ cm in length. This was taken down through the platysma and subplatysmal flaps were elevated.  The midline raphe was clearly seen and split, allowing for good visualization of the thyroid cartilage.  A ___ blade was then used to elevate the tissue off the thyroid cartilage, specifically the lower border of the thyroid cartilage, and allowing for the inferior tubercle to be visualized.  Measurements were made of the height of the thyroid cartilage midline, which was found to be ___ mm.  A mark was made at ___ mm, which was the halfway point in the midline thyroid cartilage. Another mark of ___ mm was made up from the area just posterior to the inferior tubercle.  A line was drawn corresponding to the superior edge of the true vocal fold.  Next, a window was created with an anterior aspect of the window ___ mm back from midline. The window measured ___ mm in length and ___ mm in height leaving an inferior cartilage strut.  This was drilled out using a ___ diamond drill. Next, the inner thyroid perichondrium was removed, and a small pocket was created posteriorly and anteriorly using an elevator.  Palpation posteriorly of the vocal process through the window was performed. The Montgomery sizers were then opened.  All sizers were tested, and it was found that the size ___ sizer was the best.  This allowed for a good midline push and seated nicely in the larynx.  The patient had a slightly pressed voice, although it was louder.  There was some swelling in the thyroarytenoid musculature at the time.  The implant was then carefully placed into the window.  The position of it and the voice was again tested, which again was somewhat pressed but much improved.  The area was thoroughly irrigated with saline, and hemostasis was achieved.  The midline raphe was closed with ___-0 ___ suture.  A ___ drain was placed and secured.  Platysmal flaps and subcutaneous tissue were closed with ___-0 ___ suture. The skin was then closed with ___. The patient had no breathing difficulties at the end of this case and tolerated the procedure well. This marked the end of the procedure. The patient was transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number and placed in the supine beach chair position.  A light MAC was administered by the anesthesia service. A flexible laryngoscope was suspended above the head to permit good visualization and confirmation of the vocal fold motion deficit.  A ___ cm horizontal neck incision was then marked and injected with ___% lidocaine with ___ epinephrine.  The patient was prepped and draped in the usual fashion for type 1 thyroplasty. An incision was made along a natural horizontal skin crease measuring ___ cm in length. This was taken down through the platysma and subplatysmal flaps were elevated.  The midline raphe was clearly seen and split, allowing for good visualization of the thyroid cartilage.  A ___ blade was then used to elevate the tissue off the thyroid cartilage, specifically the lower border of the thyroid cartilage, and allowing for the inferior tubercle to be visualized.  Measurements were made of the height of the thyroid cartilage midline, which was found to be ___ mm.  A mark was made at ___ mm, which was the halfway point in the midline thyroid cartilage. Another mark of ___ mm was made up from the area just posterior to the inferior tubercle.  A line was drawn corresponding to the superior edge of the true vocal fold.  Next, a window was created with an anterior aspect of the window ___ mm back from midline. The window measured ___ mm in length and ___ mm in height leaving an inferior cartilage strut.  This was drilled out using a ___ diamond drill. Next, the inner thyroid perichondrium was removed, and a small pocket was created posteriorly and anteriorly using an elevator.  Palpation posteriorly of the vocal process through the window was performed. The voice was tested at various points.  It was found that the best voice was at a ___ mm maximal depth, ___ mm back from the anterior aspect of the window (point of maximal medialization).  The implant was then carved using this ___ mm maximal medialization going down to ___ mm medialization at the anterior aspect of the window with a mid-inferior push.  The Netterville implant system was used.  The Silastic block was carved to these specifications and seated into the window.  This allowed for a good voice with a slight strain to the voice due to swelling. The area was thoroughly irrigated with saline, and hemostasis was achieved.  The midline raphe was closed with ___-0 ___ suture. A ___ drain was placed and secured. Platysmal flaps and subcutaneous tissue were closed with ___-0 ___ suture.  The skin was then closed with ___.  The patient had no breathing difficulties at the end of this case and tolerated the procedure well. This marked the end of the procedure. The patient was transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service using a ___.0 LASER-safe endotracheal tube, the table was turned and the patient was prepped and draped in the usual fashion for microdirect laryngoscopy. The Fire Risk Assessment was rated at ___. Upper and lower dentition were protected with ___ mouth guards. The ___ laryngoscope was introduced and suspended, allowing for good visualization of the larynx. Pictures were taken with 0 degree and 70 degree Hopkins rod telescopes. Wet eye pads were placed, the face was protected with wet towels, and a saline-soaked pledget was placed over the endotracheal tube cuff for laser precautions.

 The ___ LASER was set at ___ watts with a ___-millisecond pulse width and ___ pulses per second. The LASER was then used to ___. In total, ___ joules were used. Once this was accomplished, pictures were again taken with 0 degree and 70 degree Hopkins rod telescopes. The laryngoscope, pledget, mouth guards, and eye pads were removed. This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure. 

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general mask anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual fashion for microdirect laryngoscopy. The Fire Risk Assessment was rated at ___. Upper and lower dentition were protected with ___ mouth guards. Wet eye pads were placed, and the face was protected with wet towels for LASER precautions. The ___ laryngoscope was introduced and suspended, allowing for good visualization of the larynx and manual jet ventilation via a side port of the laryngoscope showed adequate chest rise and maintained good O2 levels. The stenosis began at ___ cm below the glottis with a length of ___ cm.  It was ___ by ___ mm AP dimension, which was an approximate ___% stenosis. This correlated to a Cotton-Myer grade of ___. ___ was injected circumferentially, and the CO2 LASER was attached to the micromanipulator. The CO2 LASER was used to excise wedges of scar between small mucosal bridges expanding the airway. Small mucosal bridges were preserved at ___  o'clock.  A portion of the excised tissue was sent to Pathology. The areas were then treated with ___, followed by saline rinse. Once completed, the patient was then mask ventilated until spontaneously breathing. This marked the end of the procedure.  The patient was awakened and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service using a ___.0 LASER-safe tube, the table was turned and the patient was prepped and draped in the usual fashion for microdirect laryngoscopy. The Fire Risk Assessment was rated at ___. Upper and lower dentition were protected with ___ mouth guards. Wet eye pads were placed, and the face was protected with wet towels for LASER precautions. The cricopharyngeus was clearly evident, and the diverticuloscope was placed with the posterior flange into the Zenker pouch. The ___ LASER was set at ___ watt continuous superpulse to incise through the cricopharyngeus midline all the way down to the pouch itself, and then the left and right sides of the pouch were removed, taking the mucosa off the buccopharyngeal fascia.  In the end, it appeared the fascia was all intact.  The scope was removed.  The flaps of mucosa along the edges were used to then cover with Tisseel, gluing these flaps back down around the surgical area with some exposed buccopharyngeal fascia covered in Tisseel.  Hemostasis was achieved throughout the case and there was no crepitus at the end of the case. The diverticuloscope, mouth guards, and eye pads were removed. This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.