Chapter 33

Operative Report

A detailed operative report is crucial for many reasons:

  1. Correspondence to other surgeons
  2. A record in case of future vitreo-retinal surgery
  3. Justification for billing and coding/compliance
  4. Medico-legal documentation

Operative reports can be in note form, dictated in full and drawn diagrammatically. Examples are shown below:

Operative Report: Note Form

  • 3 port, 25-gauge, 3.5mm from limbus
  • 4mm cannula
  • TPPV
  • PVD induced
  • Endodiathermy
  • Retinotomy / Drainage of SRF
  • Endolaser
  • Fluid / Air / Gas exchange (% SF6 / C3F8)
  • Sclerostomies self-sealing
  • Subconjunctival dexamethasone/cefazolin
  • Pad / Shield Posture face down

Operative Report: Full Dictation

Examples of a fully dictated operative report are provided below.

  • Patient name, medical record number
  • Consultant / attending
  • Copies sent to...
  1. Date of Procedure
  2. Surgeon
  3. Assistant
  4. Anesthesiologist
  5. Anesthesia type
  6. Preoperative diagnosis
  7. Postoperative diagnosis
  8. Operative procedure

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