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: ___

HEAD & NECK TABLE OF CONTENTS

1. Tracheostomy

2. Select Neck Dissection, Levels 1-4

3. Select Neck Dissection, Levels 2-4

4. Sentinel Lymph Node Biopsy

5. Submandibular Gland Excision

6. Superficial Parotidectomy

7. Thyroidectomy

8. Parathyroidectomy

9. Free Flap Inset and Microvascular Anastomosis

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, the patient was positioned supine with a shoulder roll. A horizontal midline neck incision was marked and the patient was then prepped and draped in the usual sterile fashion. After infiltrating the marked incision with ___ ccs of ___% lidocaine with ___ epinephrine, a transverse skin incision was made at the level of the 2nd and 3rd tracheal rings. The incision was carried down to the strap muscles, which were divided in the midline raphe down to the pretracheal fascia, which was then incised in a vertical fashion. The thyroid isthmus was divided, clamped and oversewn with ___-0 ___ suture. The anterior tracheal wall was explored and the interspace between the 2nd and 3rd rings was clearly delineated.

Using a #___ blade, a transverse incision was made between the 2nd and 3rd rings and a ___ was used to create an inferiorly based Bjork flap, which was then sutured to the skin using ___-0 ___ suture. The endotracheal tube was withdrawn and a #___ cuffed ___ tracheotomy tube was inserted. The cuff was inflated. Tidal volumes, breath sounds, and CO2 level were used to ensure sufficient ventilation and confirmation of adequate tube placement. The tube was secured to the anterior neck using ___-0 ___ suture.

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, the table was turned and the patient was prepped and draped in the usual fashion for neck dissection. 

A selective level I-IV neck dissection was performed. A horizontal neck incision was carefully designed within a skin crease and injected with ___% lidocaine with ____ epinephrine.  The skin was incised with a scalpel and subplatysmal flaps were elevated superiorly and inferiorly.  The marginal mandibular nerve was protected.  The fascia was divided inferior to the submandibular gland was divided and the posterior belly of the submandibular gland was identified.  The fascia was then elevated to the mandible.  The facial artery and vein were identified and ligated. Peri facial nodes were brought down with the packet.  We then dissected anteriorly to the mentum.  Working inferiorly we identified both anterior bellies of the digastric muscles. This was grasped with an ___ clamp and the mylohyoid muscle was exposed, elevating the packet off of level 1A down to the level of the hyoid.  

We then turned our attention to level 1B.  The submandibular gland was retracted inferiorly off of the mandible and all connecting tissue was divided.  We then identified the mylohyoid muscle and divided the neurovascular pedicle to the mylohyoid.  Once the mylohyoid was completely exposed we dissected deep to it and it was retracted. This exposed the lingual nerve, hypoglossal nerve, submandibular ganglion, and submandibular duct.  After identification of all of the structures the submandibular ganglion was bipolar coagulated and cut and the submandibular gland duct was divided and ligated.  We then rolled the submandibular gland over the posterior belly of the digastric muscle and digastric tendon and followed the digastric muscle laterally. In doing so we came across the facial artery, which was divided and ligated.  We then traced the posterior belly of the digastric to the sternocleidomastoid muscle, dividing the facial vein and reflecting the tail of parotid superiorly.  The hypoglossal nerve was identified and followed back to the internal jugular vein and accessory nerve, dividing veins and the sternocleidomastoid branch of the occipital artery.  Sternocleidomastoid fascia was then incised and rolled medially, and midline fascia was reflected laterally off of the strap muscles. We then worked medially along the sternocleidomastoid muscle to identify the accessory nerve.  This was followed to the internal jugular vein. The accessory nerve was carefully skeletonized and area IIb nodes were passed under the nerve and kept with the main specimen.  We then identified cervical rootlets and followed these superomedially to the carotid sheath.  We then skeletonized the omohyoid muscle and reflected this inferiorly.  The lateral border of the internal jugular vein was identified and the packet was divided superior to the transverse cervical vessels.  The packet was then rolled out of level III and IV and off of the carotid sheath structures, oriented and was sent to pathology for review.

The wound was irrigated and hemostasis was ensured.  A ___ drain was placed.  The neck wound was closed in layered fashion with ___ sutures. 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 endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual fashion for neck dissection. 

A selective level II-IV neck dissection was performed. A horizontal neck incision was carefully designed within a skin crease and injected with ___% lidocaine with ____ epinephrine.  The skin was incised with a scalpel and subplatysmal flaps were elevated superiorly and inferiorly.  The marginal mandibular nerve was protected.  The fascia was divided inferior to the submandibular gland and the posterior belly of the submandibular  gland was identified.  This was traced posteriorly to the sternocleidomastoid muscle, dividing the facial vein and reflecting the tail of parotid superiorly.  The hypoglossal nerve was identified and followed back to the internal jugular vein and accessory nerve, dividing veins and the sternocleidomastoid branch of the occipital artery.  Sternocleidomastoid fascia was then incised and rolled medially, and midline fascia was reflected laterally off of the strap muscles. We then worked medially along the sternocleidomastoid muscle to identify the accessory nerve.  This was followed to the internal jugular vein.  The accessory nerve was carefully skeletonized and area IIb nodes were passed under the nerve and kept with the main specimen.  We then identified cervical rootlets and followed these superomedially to the carotid sheath.  We then skeletonized the omohyoid muscle and reflected this inferiorly. The lateral border of the internal jugular vein was identified and the packet was divided superior to the transverse cervical vessels. The packet was then rolled out of level III and IV and off of the carotid sheath structures, oriented and was sent to pathology for review.

The wound was irrigated and hemostasis was ensured.  A ___ drain was placed.  The neck wound was closed in layered fashion with ___ sutures. 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: Prior to coming to the operating room the patient underwent lymphoscintigraphy. The node localized to the ___.  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, the table was turned. The lesion was located at the ___ and was measured to be ___ cm.  We then marked a ___ cm margin circumferentially around the lesion. Methylene blue was then injected in a subdermal plane. The patient was prepped and draped in the usual fashion for sentinel lymph node biopsy. 

After adequate time to allow egress of the methylene blue through the lymphatics, ___ was injected around the primary site. The lesion was then excised down to the ___. We then turned our attention to the sentinel lymph node biopsy. 

An incision was carefully designed within a skin crease ___ and injected with ___.  The skin was incised with a scalpel and subplatysmal flaps were elevated superiorly and inferiorly.  The sentinel node ___ identified in the ___ nodal basin.  This ___ confirmed with the gamma probe and via visualization of a brightly blue stained node.  We removed a ___ and sent this for pathological evaluation.  This ___ involved by metastatic ___.  Therefore we elected to ___.

The wound was irrigated and hemostasis was ensured.  A ___ drain was placed.  The neck wound was closed in layered fashion with ___. 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 endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was prepped and draped in the usual fashion for submandibular gland excision.

A ___ cm horizontal incision was marked out and injected two fingerbreadths below the mandible and inferior to the submandibular gland.  This was injected with ___. The skin was incised and subplatysmal flaps were raised. The marginal mandibular nerve was protected.  The fascia inferior to the submandibular gland was divided and the posterior belly of the submandibular gland was identified.  Careful palpation revealed a ___.  The fascia was elevated up to the level of the mandible.  The facial artery and vein were divided and ligated.  The submandibular gland was pulled inferiorly.  We then identified the mylohyoid muscle and exposed the lateral extent.  This was then elevated and retracted anteriorly.  We then identified the lingual nerve, hypoglossal nerve, submandibular ganglion, and submandibular duct.  The submandibular ganglion was ___.  We then divided the submandibular duct via suture ligation.  The submandibular gland was sent to pathology for evaluation. This demonstrated ___.  

The wound was irrigated and hemostasis was ensured.  A ___ drain was placed.  The neck wound was closed in layered fashion with ___. 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 endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned. A ___ incision was marked out and injected with ___. A 4-lead facial nerve monitor was placed and functional.  The patient was prepped and draped in the usual fashion for superficial parotidectomy.

An incision was made through the skin and subSMAS flaps were elevated to the anterior aspect of the parotid gland. The sternocleidomastoid was exposed and the great auricular nerve ___ identified and preserved.  The posterior belly of the digastric was identified.  We then created a pretragal tunnel, palpating the boney ring of the external auditory canal.  We then worked bluntly down to the level of the facial nerve.  This was identified and then dissection proceeded along the ___ division of the nerve. We then turned our attention to the ___ division. The superficial temporal vessels ___ ligated.  Once both the superior and inferior divisions were free, we worked between the two to divide the remainder of the superficial parotid gland from the underlying tissue. The parotid duct ___ identified and ligated.  The superficial parotid gland was then sent to pathology for evaluation.  This demonstrated ___.  

At the termination of this portion of the procedure, the facial nerve ___ intact and stimulatable. The wound was irrigated and hemostasis was ensured.  A ___ drain was placed.  The incision was closed in layered fashion with ___. 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 endotracheal anesthesia was successfully obtained by the anesthesia service using a monitored endotracheal tube, the table was turned. A low anterior neck skin crease was marked and injected.  After placing a shoulder roll, inserting the ground leads into the patient's shoulder, and positioning the patient, the larynx was reevaluated to ensure proper positioning of the monitored endotracheal tube. An esophageal bougie was then placed transorally. We then prepped and draped in standard fashion for thyroidectomy. 

A ___ cm incision was made and subplatysmal flaps were elevated from the thyroid notch to the sternal notch.  The strap musculature was divided at the midline raphe and retracted laterally.  Working on the ___ we worked along the lateral aspect of the gland to identify the middle thyroid vein.  This ___ ligated.  We then worked superiorly to identify the superior pole of the thyroid, developing medial and lateral planes.  Once this was complete, the superior pole vessels were divided close to the parenchyma of the gland.  The superior laryngeal nerve ___ visualized.  We then worked laterally along the gland, working close to the gland to roll the gland medially.  After carefully palpating the cricothyroid articulation, confirming that the bougie was on the side ipsilateral to our dissection, and carefully working through the soft tissue, the recurrent laryngeal nerve was identified.  The nerve was followed inferiorly.  We then identified a superior and inferior parathyroid gland and preserved both the glands and the blood supply.  Next, we divided the posterior suspensory (Berry's) ligament to free the ___ lobe from the trachea.  There was ___ a pyramidal lobe identified.  

We then turned our attention to the ___ side and worked along the lateral aspect of the gland to identify the middle thyroid vein.  This ___ ligated.  We then worked superiorly to identify the superior pole of the thyroid, developing medial and lateral planes.  Once this was complete, the superior pole vessels were divided close to the parenchyma of the gland.  The superior laryngeal nerve ___ visualized.  We then worked laterally along the gland, working close to the gland to roll the gland medially.  After carefully palpating the cricothyroid articulation, confirming that the bougie was on the side ipsilateral to our dissection, and carefully working through the soft tissue, the recurrent laryngeal nerve was identified.  The nerve was followed inferiorly.  We then identified a superior and inferior parathyroid gland and preserved both the glands and the blood supply.  Next, we divided the posterior suspensory (Berry's) ligament to free the ___ lobe from the trachea.  This completed the total thyroidectomy.  The specimen was oriented and sent to pathology for review.  This demonstrated ___.  

At the termination of the thyroidectomy, ___ was found to be electrically intact.  There ___ concerning lymph nodes.  There were ___ grossly intact parathyroid glands present on the left and ___ on the right  There ___ gross extracapsular extension of the tumor.

The wound was irrigated and hemostasis was ensured. The strap musculature ___ closed. A ___ drain was placed.  The incision was closed in layered fashion with ___. 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 endotracheal anesthesia was successfully obtained by the anesthesia service using a monitored endotracheal tube, the table was turned. A low anterior neck skin crease was marked and injected.  After placing a shoulder roll, inserting the ground leads into the patient's shoulder, and positioning the patient, the larynx was reevaluated to ensure proper positioning of the monitored endotracheal tube. An esophageal bougie was then placed transorally. We then prepped and draped in standard fashion for parathyroidectomy. 

A ___ cm incision was made and subplatysmal flaps were elevated.  The strap musculature was identified and working laterally to the ___, the internal jugular vein was identified between the sternocleidomastoid muscle and straps. Using a ___-gauge needle, a ___ mL sample of venous blood was taken and sent as a baseline PTH level.  This returned at ___ pg/mL.  

The strap musculature was divided at the midline raphe and retracted laterally.  Working on the ___ side we worked along the lateral aspect of the gland to identify the middle thyroid vein.  This ___ ligated.  We then worked superiorly to identify the superior pole of the thyroid and, hugging the gland, we rolled the gland medially.  After carefully palpating the cricothyroid articulation, confirming that the bougie was on the side ipsilateral to our dissection, and carefully working through the soft tissue, the recurrent laryngeal nerve was identified. The nerve was followed inferiorly. We then identified a ___.   

We then turned our attention to the ___ side and we worked along the lateral aspect of the gland to identify the middle thyroid vein.  This ___ ligated.  We then worked superiorly to identify the superior pole of the thyroid and, hugging the gland, we rolled the gland medially.  After carefully palpating the cricothyroid articulation, confirming that the bougie was on the side ipsilateral to our dissection, and carefully working through the soft tissue, the recurrent laryngeal nerve was identified. The nerve was followed inferiorly. We then identified a ___. Following gland removal, using a ___-gauge needle, a ___ mL sample of venous blood was taken and returned at ___ pg/mL.  At the termination of the parathyroidectomy, ___ were found to be electrically intact. There ___ concerning lymph nodes. There were ___ grossly intact parathyroid glands present on the ___ left side and ___ on the right. 

The wound was copiously irrigated and hemostasis was obtained. The strap musculature ___ closed. The wound was closed in a layered fashion with ___.  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. 

The flap was then inset into the ___ and ___. We then draped the vascular pedicle into the neck and began preparing the vessels.  The ___ artery, ___ vein and ___ vein were identified as donor vessels.  Vein ___ clamps were placed on each vein and the distal end freshened, using copious aliquots of heparinized saline to flush the veins.  There ___ clots noted within the vessel after ligating them.  The artery was then clamped using an ___ clamp and the distal end was ligated and freshened.  The vessel was carefully and atraumatically dilated and then using microvascular technique under ___ loupe magnification, the adventitia was cleared several mm from the distal end.  Papaverine-soaked gelfoam was placed around the artery while preparing the veins. The vessels were irrigated with heparinized saline and then the clamp was released.  There ___ adequate arterial flow from the vessel.  It was them reclamped and irrigated. We then positioned the flap vessels.  The flap artery and veins were similarly prepared, and draped with good geometry in the neck. We then placed two stay sutures using ___.0 ___ sutures on the donor and flap arteries.  The first stitch was then run and tied to the short end of the second, and the artery was flipped.  The suture line was inspected to ensure the artery had not been backwalled. We then irrigated with heparinized saline and proceeded to run the second suture and tie to the short end of the first. We then flipped the vessel back into anatomic position.

A ___ venous coupler was used to anastomose the ___ vein to the ___ vein.  The second venous anastomosis was performed using a ___ coupler between the ___ vein and the ___ vein.  We then released the clamps, veins first, followed by the artery and had excellent flow. A rescue stitch ___ required.  A ___ doppler was then placed just distal to the arterial anastomosis and positioned using a surgical clip.  We had good flow and signal through this.  This was sutured to the patient's shoulder and a single suture was used to position it adjacent to the incision line.  

The wound was irrigated and hemostasis was ensured.  A ___ drain was placed.  The neck wound was closed in layered fashion with ___ sutures. The patient was awakened and transferred to the recovery room in stable condition. 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.