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Operative Report[1] 



Blair General Hospital

123 Main Street

Anytown, USA 56789[2] 



Patient Name:  Betty Doe



Date:  January 1, 2005[3] 



Preoperative Diagnosis:[4]   Bilateral upper eyelid dermatochalasis[5] 



Postoperative Diagnosis[6] :  Same



Procedure[7] : Bilateral upper lid blepharopoasty[8] , (CPT 15822) [9] Surgeon[10] :  John D. Good, M.D.

Assistant[11] :  N/A [12] NAME:  Doe, William[13] 

Anesthesia:[14]   Sedation  with Lidocaine with l:100,000 epinephrine[15] 



Anesthesiologist:[16]   John Smith, M.D. Dictated by[17] :  John D. Good, M.D.



Indications for procedure:[18] 

This 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction. The


procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient.[19]   All questions have been thoroughly answered, and the patient understands the surgery indicated.  She has requested this corrective repair be undertaken, and a consent was signed[20] .


The patient was brought into the operating room and placed in the supine[21]  position on the operating table[22] .  An intravenous line[23]  was started, and sedation and sedation anesthesia [24] was administered IV after preoperative P.O. sedation[25] . The patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously[26] .


The excess and redundant skin[27]  of the upper lids producing redundancy and impairment of lateral vision[28]  was carefully measured, and the incisions[29]  were marked [30] for fusiform excision[31]  with a marking pen.  The surgical calipers[32]  were used to measure the supratarsal incisions[33]  so that the incision was symmetrical from the ciliary margin bilaterally.[34] 


The upper eyelid areas were bilaterally injected with 1% Lidocaine with 1:100,000

Epinephrine for anesthesia and vasoconstriction[35] .  The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.[36] 

The face was prepped and draped in the usual sterile manner. [37] After waiting a period of approximately ten minutes for adequate

vasoconstriction,[38]  the previously outlined excessive skin of the right upper eyelid

was excised with blunt dissection.[39]   Hemostasis[40]  was obtained with a bipolar cautery[41] .  A thin strip of orbicularis oculi[42]  muscle was excised in order to expose the orbital septum[43]  on the right.  The defect in the orbital septum was identified, and herniated orbital fat was exposed[44] . The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit[45] .  A similar procedure was performed exposing herniated portion of the nasal pocket[46] .  Great care was taken to obtain perfect hemostasis[47]  with this maneuver.  A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion[48] .  Careful hemostasis had been obtained on the upper lid areas. The lateral aspects of the upper eyelid incisions were closed [49] with a couple of interrupted[50]  7 – 0 blue prolene[51]  sutures.


At the end of the operation the patientʼs vision and extraocular muscle movements were checked and found to be intact[52] .  There was no diplopia[53] ,no ptosis[54] , no ectropion[55] .  Wounds were reexamined for hemostasis, and no hematomas[56]  were noted. Cooled saline compresses[57]  were placed over the upper and lower eyelid regions bilaterally,

The procedures were completed without complication and tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.[58] 


The patient was released to return home in satisfactory condition.










John D. Good, M.D.[59] 



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An operative report is a document that every surgeon must generate (be it typed or dictated and transcribed) for every surgical procedure that is performed. 


The general outline is for a brief bullet point style introduction followed by a "indications" section followed by the actual description of the surgery performed.


Surgeons do this soon after an operation, think of it as a written play by play of the operatioin. The goal is to have a document in the patients record that allows any future doctor to know exactly what was performed.  T

he operative report is also how a surgeon and hospital  get paid for the procedures they perform.

The location of the surgery should always be clearly documented in the operative report.  This is important for anyone looking for further records to be able to find other documents from the time of surgery. Examples include nursing and anesthesia records.

The date of surgery is very important for postoperative care.  It allows everyone to know how far from surgery the patient is.

The Preoperative diagnosis is the the problem that the patient is having.  This is the reason the surgeon believes the patient requires surgery.

Bilteral - Both sides

Upper - the top eyelid closer to the eyebrow

Dermatochalasis - this is a condition that involves a droopy or baggy eyelid. dermato(skin) chalasis( relaxed/baggy) (click on word for further info)

The postoeprative diagnosis is the condition that the surgeon has determined after the surgery.


For example a preoperative diagnosis may be gunshot wound, but after the surgery the surgeon found out the spleen was lacerated so he or she adds this to the postoperative diagnosis. Its impossible to know that the spleen was lacerated before surgery so that is why it wouldn't be in the preoperative diagnosis.


Many times the postoperative diagnosis is the same as the preoperative diagnosis , sometimes it is different depending on the surgery type and what was found.

the procedure is the actual surgery that was performed. This is the "name" of the surgical procedure.

Bilteral - both sides (in this case both eyes)

Upper Lid - the top eyelids closest to the eybrow)

Blepharoplasty - This is a surgery where the eyelid is formed to a different shape usually because of drooping or cosmetic defect.  Blepharo ( eyelid) Plasty (shaping) Click on word for more info.

CPT - stands for current procedural terminology . This is a numerical code developed by the american medical association that allows surgeons to bill and categorize their surgeries.  Close to all common surgeries have CPT codes that are constantly changing with time.  It doesn't mean much to the patient as it is more for specifying the surgery for billing.

This is the surgeon of record for the procedure. This sometimes also says attending surgeon or primary surgeon.  Basically, the surgeon performing the procedure and in charge.

This is the person assisting the surgeon.  This can sometimes be a certified surgical assistant (S.A.) or a surgeon in training such as a resident surgeon.  The assistant does not perform the procedure but often helps with holding instruments and performing tasks that require more than one set of hands.  They are an integral part of an operating team.

In this case, given that this is a small procedure an assistant wasn't needed so the surgeon denotes N/A or not applicable.

This is a sample template so the name of the assistant would normally be placed here.

This bullet point lets you know the type of anesthesia that was used during the surgery.  May different types of anesthesia exist. Some procedures don't require any anesthesia (think removing a splinter) some require general anesthesia ( being fully under).

The sedation anesthesia makes the patient drowsy sometimes called twilight anesthesia. In this case the surgeon used Lidocaine ( a numbing medication) with epinephrine ( a medication to prevent bleeding) and injected it into the skin before the procedure. think of this like novocaine at the dentist.

The anesthesiologist is a vital part of the surgical team and monitors the patients at all times during surgery.  Anesthesia can be provided by an anesthesiologist or a nurse anesthetist  (CRNA) under the supervision of an anesthesiologist.

This is who dictated the operative reports.  Usually, it is dictated by the surgeon who performs the procedure. Sometimes a different doctor associated with the procedure as an assitant may dictate the procedure before the lead surgeon signs off.

Indications for procedure is a section of the operative report where the surgeon explains why the patient is having surgery.  It often describes the condition and why it requires surgical treatment. 


Sometimes, in this section, the surgeon will also discuss the conversations had with the patient prior to surgery regarding risks and benefits of the procedure.  sometimes that conversation is documented in the office chart of the patient.

The surgeon documents that he talked with the patient regarding;

procedure- what the surgery entails

alternatives - what can be done besides surgery

risks- potential bad things that could happen during surgery

limitations- what the surgery may not be able to fix

The surgical consent is a document that the patient is required to read and sign prior to an operation.  it gives permission to the surgeon to perform the procedure.  This is done for nearly all surgeries.  Exceptions do occur including emergency trauma and patients who can't consent for themselves.

Supine : The patient was laying flat of their back.

Most operations are performed on a specialized table made for performing surgery. It has specialized functions that allow the surgeon to access the patient in the most convenient way.

this is an needle that places a tubing line  into the patients vein. This IV allows for medications and fluids to be given to the patient while they are asleep and after surgery.

The sedation anesthesia makes the patient drowsy sometimes called twilight anesthesia. The medication to make you drowsy goes in through the IV line that was started into your vein.

PO = by mouth

Usually before you go to the operating room anesthesiologists may give you some medication by mouth to relax you a little bit.

The anesthesiologist monitors your cardiac rate( heart rate), Blood pressure ( the pressure of blood in your body) and oxygen saturation ( a marker of how well you are breathing) .  These measurements are done with specific monitors that you are hooked up to in the operating room.  Sometimes you are awake when they are putting the stickers or blood pressure cuff on, that is normal.

This surgery was done for baggy skin around the eyes. excess is too much and redundant  is how surgeons say there is extra  tissue that is present but not needed.

In this case the extra tissue was causing problems with eyesight especially when looking to the sides.

An incision is when a scalpel (knife) if used to make a cut in the skin. This is a very precise technical skill that requires years of training.

It is very common for surgeons to mark out ( or draw) the incisions they are planning to make prior to actually cutting the skin.  Sometimes this is done before surgery.

Fusiform - think oval shaped or wider at the middle and tapering at the ends.Excision is removing something.    fusiform excision is removing a oval piece of tissue.

An extremely precise ruler used to make measurements in surgery.

this is an incision made above the fold of your top eyelid.

the surgeon is drawing the planned surgery  after measuring the perfect distance between the corners of the top eyelid.  this was done to make the procedure symmetrical ( equal and balanced on both sides)

this describes the surgeons use of the numbing medication prior to actually making a cut on the skin.  The Lidocaine (numbing medication) and the epinephrine ( medication to stop bleeding.) are injected into the area where the surgery is going to occur.

This is describing where the injected medication was placed.  In this case the injection was in the plane (layer of skin) was superficial (above) and external (outside) of the orbital septum ( the layer protecting your eye)

Prepped and Draped - The importance of keeping a clean and sterile environment in the operating room is one of the most important aspects of safety.  Surgeons may say it in different ways but cleansing and protecting the surgical field is done in nearly every surgery.


Prepped - this is how the skin is cleansed prior to surgery.  the skin must be cleansed using a special soap or cleansing solution in order to clean any bacteria off the skin before performing the surgery.


Draped - this is the process of placing sterile surgical drapes or cloths to protect the area of surgery from contamination.


The concept of sterile prepping and draping goes back centuries and is one of the sacred traditions of safe surgical procedures.

Epinephrine (or the medication to help stop bleeding during surgery) was injected so the surgeon waited for its effect to kick in prior to starting the surgery.

excised - removed the excess tissue in this case


blunt dissection - this is a surgical technique where either a tool or a finger is used to manipulate tissue.  it differs from sharp dissection where a knife or scissors is used to cut tissue.

Hemostasis - bleeding has stopped and is controlled.

Bipolar Cautery - is a device that is used to stop bleeing or dissect tissue. It is a controlled precise burn of tissue.  it singes the tissue while it cuts to stop bleeding or sears blood vessels so that they don't bleed.

One of the circular muscles of the eye.

The layer of tissue separating the eyelid from the eyeball.

herniated - outpouching or sticking out.


Orbital fat - normal fat that sits around the eyeball.

the abnormal fat that was sticking out was carefully removed and that portion that was left behind was singed with the cautery device to stop bleeding.

a similair procedure was done close to the nose where the eyelid meets the nose to remove the out pouching tissue at this area as well.

control and stopping of any bleeding.

the same procedure was done on the other side.

closure - is the process of closing up the skin after surgery. there are many ways to do this.

interrupted - interrupted sutures  means that multiple stitches were used to close a wound. and each  stitch was placed individually.

7-0 - the size of the  thread

blue - the color of the thread

prolene - a type of thread that is used to stitch wounds closed.

the surgeon double checked to make sure everything was working with eyesight and eye movements after the surgery.

diplopia - double vision

ptosis - dropping eyelid

ectropion - eyelid turned inside out.

Hematoma - collection of blood pooling below the skin.

cooled saline compresses - gauze that was wet with cold saline (salt water) solution were applied to the eyelids on both sides.

The final paragraph is often used to describe how the patient did during the surgery and any post surgery information.

Physician name and signature. Often the document is intially dictated and subsequently typed.  If there is no signature and no documentation of an electronic signature, the document may be a draft or non certified copy.