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: ___

SINUS SURGERY TABLE OF CONTENTS

1. Full FESS

2. Endoscopic Septoplasty

3. Open Septoplasty

4. Bilateral Inferior Turbinate Reduction

5. Endoscopic Transphenoidal Pituitary Surgery

6. Transnasal Endoscopic Orbital Decompression

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 endoscopic sinus surgery. The computer-assisted navigation device was brought into the field. This was registered and confirmed for accuracy.

We then proceeded with a left-sided sinus surgery. The middle turbinate was gently medialized. We identified the uncinate process and dissected this in a retrograde fashion with a ___ and removed it in its entirety.  We then used an angled scope to visualize the natural os of the maxillary sinus and dilated this posteriorly.  We then incorporated this into a wide antrostomy with a ___.  Hyperplastic tissue and polyps were removed from within the sinus with a ___.  

We then identified the ethmoid bulla. We entered into this inferiorly and medially in its natural os and fractured this forward.  We then removed this with ___ instrumentation.  We continued to dissect additional anterior ethmoid cells and identified the lamina papyracea in this area.  We then identified the basal lamella and crossed through this in an inferior medial fashion. We identified the superior turbinate on the posterior aspect of this and left this in situ.  We then dissected posterior ethmoid cells from medial to lateral last skeletonizing the orbit and working towards the skull base, confirming our location with navigation.  

At this juncture, we elected to perform our sphenoidotomy.  Using the computer-assisted navigation device, we identified the natural os of this just medial to the superior turbinate. We then dilated the os of the sphenoid sinus with a ___.  We then opened this widely in all directions with a ___.  Hyperplastic mucosa and debris were removed from the sinus.  We then continued to dissect additional anterior and posterior ethmoid scales skeletonizing the entire to the skull base and orbit in this fashion.

At this juncture, we turned our attention to the patient's frontal sinus.  We used a computer-assisted navigation device to navigate into this area. Once we had identified the natural outflow tract, we fractured the agger Nasi cell anteriorly and removed this. We then identified and dissected additional bullar and supra-bullar cells in this area.  We then opened the floor of the frontal sinus widely in all directions with ___ instrumentation. We then irrigated out the sinus cavities on this side and hemostasis was obtained.

We then proceeded with a right-sided sinus surgery. The middle turbinate was gently medialized. We identified the uncinate process and dissected this in a retrograde fashion with a ___ and removed it in its entirety.  We then used an angled scope to visualize the natural os of the maxillary sinus and dilated this posteriorly.  We then incorporated this into a wide antrostomy with a ___.  Hyperplastic tissue and polyps were removed from within the sinus with a ___.  

We then identified the ethmoid bulla. We entered into this inferiorly and medially in its natural os and fractured this forward.  We then removed this with ___ instrumentation.  We continued to dissect additional anterior ethmoid cells and identified the lamina papyracea in this area.  We then identified the basal lamella and crossed through this in an inferior medial fashion. We identified the superior turbinate on the posterior aspect of this and left this in situ.  We then dissected posterior ethmoid cells from medial to lateral last skeletonizing the orbit and working towards the skull base, confirming our location with navigation.  

At this juncture, we elected to perform our sphenoidotomy.  Using the computer-assisted navigation device, we identified the natural os of this just medial to the superior turbinate. We then dilated the os of the sphenoid sinus with a ___.  We then opened this widely in all directions with a ___.  Hyperplastic mucosa and debris were removed from the sinus.  We then continued to dissect additional anterior and posterior ethmoid scales skeletonizing the entire to the skull base and orbit in this fashion.

At this juncture, we turned our attention to the patient's frontal sinus.  We used a computer-assisted navigation device to navigate into this area.  Once we had identified the natural outflow tract, we fractured the agger Nasi cell anteriorly and removed this.  We then identified and dissected additional bullar and supra-bullar cells in this area.  We then opened the floor of the frontal sinus widely in all directions with ___ instrumentation. We then irrigated out the sinus cavities on this side and hemostasis was obtained.

At this juncture, the entirety of the nasal cavity was irrigated out. Hemostasis was obtained. 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 endoscopic sinus surgery. We began by examining the patient's nasal cavities. There was a deviation towards the ___. We therefore opted to carry out a septoplasty. After infiltration with local anesthetic, we made a ___-sided incision with a ___ approximately ___ cm behind the mucocutaneous junction. We then dissected a submucoperichondrial plane posteriorly. We then made a vertically oriented chondrotomy leaving approximately a ___ cm caudal strut. We then crossed the contralateral side and raised this mucosa in a submucoperichondrial plane. We then made a horizontally oriented dorsal chondrotomy with ___. We preserved a ___ cm dorsal strut in this area. We then dissected and removed the intervening portions of deviated bone and cartilage. After this had been completed, we re-examined the nasal airway and were satisfied with our improved access. We then irrigated out this space and reapproximated the flaps.  A quilting stitch was carried out with ___.0 ___ suture. 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 sterile fashion. The nasal cavities were decongested using cottonoid soaked with ___. Following injection of ___% lidocaine ___ with epinephrine, a #___ blade was used to make a hemitransfixion incision. Dissection was then carried down to the submucoperichondrial plane. Submucoperichondrial flaps were raised with a ___ elevator. A ___ was then used to make an incision preserving at least a centimeter and half of cartilage along the dorsum as well as anteriorly. The contralateral submucoperichondrial flap was then elevated widely. The involved section of the cartilaginous and bony septum was then removed. The mucoperichondrial flaps were left intact (describe if any rents were encountered). The ___ was then used to outfracture the inferior turbinates bilaterally. A ___-0 ___ suture was used to close the hemitransfixion incision. A ___-0 ___ was used to quilt the septum. 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 endoscopic sinus surgery. We then proceeded with a bilateral submucosal inferior turbinate reduction. After infiltration with local anesthetic, an incision was carried out with a curved ___ blade over the head of the left inferior turbinate. We then dissected back in the submucoperiosteal plane, exposing the bone of the inferior turbinate. We then removed intervening portions of bone. We then performed a submucosal reduction with the ___ and then outfractured this. We then proceeded in a very similar fashion on the right side. Mucosal incision was made and a submucoperiosteal dissection was carried out. Intervening portions of bone were removed. A submucosal reduction was then made with the ___ and was then outfractured. At this juncture, the entirety of the nasal cavity was irrigated out. 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 endoscopic sinus surgery. The computer-assisted navigation device was brought into the field. This was registered and confirmed for accuracy. 

The nasal cavity was decongested with topical ___ epinephrine.  The bilateral inferior middle and superior turbinates were outfractured.  The left natural os of the sphenoid sinus was identified. This was gently dilated in open with a ___.  Similarly, the natural os of the right sphenoid sinus was also identified and opened with a ___.  We then carried out a limited posterior septectomy.  A ___ was used to cross the nasal septum from left to right behind the head of the middle turbinate at the same level of the natural os of the sphenoid sinus.  This was then carried posteriorly with a ___. At this juncture, we secured bilateral rescue flap pedicles.  The mucosa over the posterior septum and the face of the sphenoid was gently retracted towards the choana.  A ___ was then used to remove the entirety of the face of the sphenoid down to the level of the clival recess.  The keel of the rostrum was then removed until it was flush with the floor of the sinus and the clival recess. We then worked to expand the common sphenoid cavity widely in all directions gaining access to the planum in the clival recess. The intersinus septation was also removed with ___ instrumentation.

At this juncture, the neurosurgical team entered the field.  We then worked as a 2 surgeon 4-handed technique in order to dissect and remove the tumor.  After tumor resection, hemostasis was ensured. There was ___ CSF leak noted during surgery. Irrigation was carried out.  A combination of Gelfoam and Surgicel was placed into this area.  We then placed the rescue flap pedicles back onto the remnant of the posterior septum and secured these in place 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 sterile fashion. The nasal cavities were decongested using cottonoid soaked with ___; ___% lidocaine with 1:100,000 epinephrine was injected into the root of the middle turbinate. Next, a ___ was used to take down the right uncinate process. A 30-degree scope was then used to visualize the infundibulum and a ___ was used to perform the maxillary antrostomy. A ___ was used to take down the right ethmoid bulla. The lamina papyracea was then identified on the lateral wall of the ethmoid bulla. The basal lamella was then entered, and the superior turbinate was identified. The posterior ethmoid air cells were then taken down in sequence from anterior to posterior until the skull base was identified posteriorly and superiorly.

The mucosa overlying the lamina papyracea was removed until the underlying bone was exposed. The lamina papyracea bone was exposed up to the level near the frontal sinus floor superiorly and near the maxillary antrostomy roof inferiorly. A ___ was used to gently fracture the lamina papyracea and a ___ was used to remove the bone until periorbitum was fully exposed. A ___ was used to create multiple horizontal cuts through the superior orbit to allow for herniation of the orbital fat. An inferomedial strut of bone was maintained inferiorly to support the eye. Cottonoid pledgets soaked with ___ were then placed into the right nasal cavity while attention was turned to the left orbital decompression.

Next, in a similar fashion, ___% lidocaine with ___ epinephrine was injected into the root of the middle turbinate. The uncinectomy was performed using a ___. The maxillary  antrostomy was then made using a ___. The ethmoid bulla was entered using a ___ and taken down using ___. The basal lamella was then entered and posterior ethmoid air cells were taken down sequentially. The superior turbinate was identified. The mucosa overlying the left lamina papyracea was removed. A ___ was used to fracture the lamina papyracea, and the overlying bone was removed. Once there was adequate exposure of the periorbitum, a ___ was used to create multiple horizontal incisions through the periorbita to allow for herniation of orbital fat. Once again, an inferomedial orbital floor strut was kept intact. Hemostasis was obtained using cottonoid soaked with ___ epinephrine. These cottonoids were left in place until the patient was returned to anesthesia for awakening and extubation. Upon extubation, the cottonoids in the nasal cavity 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.