Better For Everyone: The Case for Operative Note Templates

(Template Series 3/3)

Create a template for your most common operative note and test how much time it saves you this week.

Are anyone else’s least favourite dictations your OR/procedure notes?

It’s usually at the end of the day. You’re tired, probably need a snack and want to go home. Instead, you need to relive all your procedures in painful detail.

At the end of a particularly gruelling OR day, while (hangrily) dictating the same operative steps for the third time that day, I hit my breaking point. While making commiserating eye contact with fellow surgeons in the dictation room, I realized that we were each dictating a procedure we did all the time. The same procedure, the same steps done in the same way, almost every time.

Light bulb moment: Why the heck had I not created a template for common procedure and operative dictations?

How I Use Procedure & OR Templates

We all know, not every case goes according to plan. You might come across unexpected findings or an adjustment to the steps. These always need a full dictation.

But most routine procedures do follow the same setup, steps and closure. That’s exactly where a template shines.

For these types of cases all I do now is quickly run through the following information:

• patient information
• anesthesia and assist team,
• pre and post-op diagnoses,
• procedure name(s) and
• indication for surgery
• +/- hardware serial numbers.

Then come the magic words: “insert [name of procedure] template,” and the description (aka the longest part of the dictation) gets instantly added in seconds. Let me tell you – this dopamine spike is real. Brings a smile to my face every time.

In my hospital, we still dictate OR notes. However, if you use Epic or another EMR, you can make an operative template just like a follow-up or consult template.

What about cases where implant, hardware or unique specimen details need to be added?

Great question. For my practice, I sometimes need to add specific hardware serial numbers or resection weights. In those instances, I add them just prior to the main procedure description with their own sub-heading. This avoids having to dictate the entire note just to embed them within the body of the note.

Operating isn’t part of my practice – will this work for me?

If operating isn’t part of your practice, anything procedural applies: excisions under local anesthetic, upper or lower GI scopes, TEEs, joint injections, arterial or central line placement. The list goes on. If you do procedures, you have opportunity.

Why You Should Seriously Consider Procedure and OR Notes Templates

Yes, this will definitely save you a lot of time. And sanity.

So you don’t think I’m too deep in my own biases – the literature shows other advantages of using operative note templates. These include fewer errors, less time to complete, faster turnaround time to a verified report being available in the patient’s medical record, reduced transcription costs and higher completion rates.

Those are some pretty big win-wins for the patient, for you and for the system.

Try Creating Your Own Procedure and OR Notes Template!

This might not be for everyone – do what’s best for you, your practice and your patient.  If you:

• don’t like doing a procedure the same way every time or
• prefer the flexibility of adding some nuanced descriptors to each case

then you should probably sit this one out.

But if you are open to trying it – start with one. See how it goes. But I’ll bet – like a certain potato chip company – it’s a challenge to just stop at one.