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: ___

SLEEP SURGERY TABLE OF CONTENTS

1. Drug-Induced Sleep Endoscopy

2. Expansion Sphincter Palatopharyngoplasty with Tonsillectomy

3. Implantation of Hypoglossal Nerve Stimulator

DICTATION OF EVENTS (without BIS monitor): The patient was brought into the operating room and identified by name and medical record number. The patient was made comfortable on the operating table and the lights were dimmed. Propofol infusion was then started at ___mcg/kg/min. The flexible endoscope was passed through the nasal cavity to observe the retropalatal and hypopharyngeal space down to the larynx. No abnormal masses or lesions were noted. Propofol infusion was titrated to the point that the patient was not responding to verbal stimuli but was breathing spontaneously. The findings were noted as below. 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 (with BIS monitor): The patient was brought into the operating room and identified by name and medical record number. The patient was made comfortable on the operating table and the lights were dimmed. Propofol infusion was then started at ___ mcg/kg/min with a BIS monitor in place.  The fexible endoscope was passed through the nasal cavity to observe the retropalatal and hypopharyngeal space down to the larynx.  No abnormal masses or lesions were noted. Propofol infusion was targeted for a BIS monitor reading of the low- to mid-60s. The findings were noted as below. 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. 

INTRAOPERATIVE FINDINGS:

V-[no/partial/complete/not visualized] [anteroposterior/lateral/concentric] collapse at the velum 

O-[no/partial/complete/not visualized] lateral wall collapse at the level of the oropharynx 

T-[no/partial/complete/not visualized] anteroposterior collapse at the tongue base 

E-[no/partial/complete/not visualized] [anteroposterior/lateral] collapse at the epiglottis; retroflexion of epiglottis proportionate to BOT hypertrophy

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 90 degrees and the patient was prepped and draped in the usual fashion for tonsillectomy and palatophyarngoplasty. 

The oropharynx was exposed with use of a mouth gag. The left tonsil was grasped with a tenaculum. Electrocautery at a setting of ___ was used to incise the anterior pillar, then a plane was developed between the tonsil and the superior constrictor muscle. This was continued until the tonsil was removed in its entirety. Hemostasis was achieved with suction cautery at a setting of ___. The right tonsil was removed in the exact same fashion. 

___% lidocaine with ___ epinephrine was then injected into the soft palate. A needle-tipped electrocautery wand was used to elevate the left palatopharyngeus muscle from the tonsillar fossa, keeping it attached superiorly. The muscle flap was started about 1/2 to 2/3 of the way down its length. A ___-0 ___ suture was placed around the incised distal end of the muscle in a figure-of-eight fashion. An incision was made with the needle tip bovie over the area of the pterygoid Hamulus. Dissection with a right-angle hemostat was done to develop a tunnel from that incision to the tonsillar fossa. The cut end of the palatopharyngeus muscle and the sutures around it were tunneled up to the superolateral incision. The suture was then thrown into this area to suspend the palatopharyngeus muscle superolaterally. The right palatopharyngeus muscle was then raised in the same fashion and suspended superolaterally. The tonsillar pillars were then closed superiorly with ___ sutures. The mucosal incisions were closed with ___ suture. The distal uvula mucosa was truncated with electrocautery. This wound was closed with ___ suture. Hemostasis was confirmed and Exparel was injected into the soft palate and tonsillar fossae bilaterally. 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. 

IMPLANTS: 

1. Inspire stimulation lead 

2. Inspire sensor lead 45 cm

3. Inspire IV 3028 (generator)

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 180 degrees and the patient was prepped and draped in the usual sterile fashion. The patient was positioned with a roll/bump to elevate the right side of the body and extend the neck. The NIM hypoglossal nerve sensing leads were then placed in the tongue. The red lead was placed on the lateral aspect and the blue lead was placed deep into the genioglossus. A rolled-up gauze for a bite block was then placed in the left side of the mouth. The head was rotated slightly to the left and the incisions were marked out. A 5-cm incision was planned one fingerbreadth below the mandible and approximately 1 cm lateral to the midline on the right side of the neck. A second incision was planned for the generator on the anterior chest inferior to the clavicle. A third incision was made on the right lateral chest wall space for the respiratory sensing lead, overlying the 5th or 6th intercostal space. These incisions were then infiltrated with a total of ___ mL of ___% lidocaine with ___ epinephrine, and the area was prepped and draped in the usual sterile fashion.  Ioban dressing was then applied to the skin of the neck and chest, and a 1010 drape was placed over the mouth and face. Surgical drapes were then placed, and the NIM monitoring equipment was confirmed to be functioning. The surgery was then started with the anterior submandibular incision. This was carried down through a subplatysmal plane. The anterior portion of the submandibular gland was identified and the anterior belly of the digastric was also identified. The tendon of the digastric tendon was freed. Dissection was then continued deep to the anterior belly of the muscle and the mylohyoid was identified. Once the lateral/posterior aspect of the mylohyoid was dissected free, this was pulled anteriorly. The hypoglossal nerve was then identified. The ranine veins were ligated as needed. Dissection was continued along this nerve over the hyoglossus muscle. The nerve was followed until it descended medial past the anterior border of the hyoglossus muscle. Once the nerve passed anterior to the hyoglossal muscle, an area of planned stimulation was noted, and the C1 branch was noted coming off inferiorly. The bipolar stimulator was used to test the stimulation points on the hypoglossal nerve and the area of cuff was planned at the anterior edge of the hyoglossus muscle. Exclusion branches were clearly identified and left outside the cuff. NIM monitoring identified stimulation of the retractor branches and a mixed presentation with T/V and protrusor branches identified.  Appropriate movement of the hyoglossus muscles was noted with red channels on the NIM corresponding to retractor muscles. Genioglossus activiation was noted with the protrusor branches and correct anatomic correlates.  The stimulation lead cuff was then placed around the nerve. The lead was then passed inferiorly to the anterior belly of the digastric muscle and sutured onto the muscle with ___-0 ___ sutures. Once this was completed, the hemostasis was achieved and the pocket was irrigated thoroughly. A wet sponge was then placed over the implant.  

Next, attention was turned towards the sensing lead. This was made along the right chest. Dissection was continued through the subcutaneous fat to the level of the ribs. Dissection was continued between the bellies of the serratus muscle in the intercostal space, until the external and internal intercostal muscles were identified. The fibers of the external intercostal muscles were spread to identify the internal muscles, and then the sensing lead was passed in this space between the muscle layers. Once this was in place, this was sutured into place with ___-0 ___ sutures around the distal collar. The anchors were secured with silk sutures. The pocket was then irrigated thoroughly and packed with a saline-soaked sponge. Finally, the third incision was started in the subclavicular area, about two finger-breadths inferior to the clavicle.  This incision was carried through the subcutaneous fascia. The pectoralis fascia was identified and pocket was created between the subcutaneous fat and the muscle fascia. Once an adequate pocket size was noted, hemostasis was achieved and the pocket was irrigated thoroughly.  The tunneler was then used to create a subcutaneous tunnel from the chest lead to the subclavicular incision, and the sensing lead was passed through this pocket.  Similarly, a tunneler was used from the neck incision to the subclavicular pocket and the stimulating lead was passed. The IPG implant was passed onto the field. The leads were attached, and the generator was placed into the third pocket. This was then sutured in place with ___-0 ___ sutures. The device was then activated and tested with good bilateral protrusion of the tongue base noted. This was tested with the surgical team and device representatives. Visual confirmation showed appropriate movement of the tongue along with NIM and characteristic device feedback. The device was then deactivated, and attention was turned towards closure.  

The submandibular incision was closed with ___-0 ___ deep sutures through the platysmal layer and deep dermal layer and ___-0 running subcuticular ___.  Dermabond was applied over the wound. The subclavicular incision was closed with deep ___-0 ___ sutures and a running ___-0 ___. Similarly, the chest wall incision was closed in the same fashion. Dermabond was applied to both of these wounds as well. Long-acting local anesthetic was placed in the incision sites. Once this was completed, a pressure dressing was applied to all three wounds. 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.