The Operative Note
This chapter gives the fundamentals of writing a good operative note. It also discusses the (several) purposes of the note. The operative note is an integral part of the medical care provided to the patient and reflects the quality of care delivered. Its value may not be immediately apparent, particularly to the harried surgical resident. If the patient does well and does not require any further care for that problem, it may become a purely historical document. However, its value cannot be underestimated when a patient presents in the future needing additional related care at the same or another healthcare facility. Such need may arise when the original healthcare provider is no longer available and a different healthcare provider is going to assume care of that patient. Similarly if another operation becomes needed in the future, the pertinent details of what was performed during that operation cannot be undervalued.
KeywordsRecurrent Laryngeal Nerve Carotid Endarterectomy Operative Note Hypoglossal Nerve Surgical Resident
- Hoballah JJ, Scott-Conner CEH, editors. Operative dictations in general and vascular surgery. 2nd ed. New York: Springer Science + Business Communication; 2011.Google Scholar