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: ___

FACIAL PLASTIC SURGERY

1. Septorhinoplasty with Bilateral Inferior Turbinate Reduction

2. SMAS Flap Face Lift

3. Deep Plane Face Lift

4. Direct Brow Lift

5. Endoscopic Brow Lift

6. Trichophytic Brow Lift

7. Upper Eyelid Blepharoplasty with Fat Removal

8. Lower Lid Blepharoplasty with Fat Transfer (Transconjunctival, Preseptal)

9. Upper Eyelid Weight Placement

10. Tarsal Strip Lateral Canthopexy with Canthotomy and Cantholysis

11. Otoplasty

HEAD & NECK SURGERY

1. Tracheostomy

2. Select Neck Dissection, Levels 1-4

3. Select Neck Dissection, Levels 2-4

4. Sentinel Lymph Node Biopsy

5. Submandibular Gland Excision

6. Superficial Parotidectomy

7. Thyroidectomy

8. Parathyroidectomy

9. Free Flap Inset and Microvascular Anastomosis

LARYNGOLOGY

1. Flexible Laryngoscopy

2. Awake Per Oral Vocal Cord Injection

3. Awake Transcervical Vocal Cord Injection

4. Awake KTP LASER Ablation of True Vocal Cord lesion

5. Microdirect Laryngoscopy with Vocal Cord Injection

6. Gore-Tex Type 1 Thyroplasty

7. Montgomery Type 1 Thyroplasty

8. Netterville Type 1 Thyroplasty

9. Microdirect Laryngoscopy with LASER

10. Subglottic Stenosis LASER with Jet Vent

11. Microdirect Laryngoscopy with Zenker’s Diverticulotomy

OTOLOGY & NEUROTOLOGY

1. PE Tubes

2. Butterfly Graft Myringoplasty

3. Transcanal Tympanoplasty with Cartilage Graft

4. Intact Canal Wall Tympanomastoidectomy for Chronic Otitis Media

5. Intact Canal Wall Tympanomastoidectomy for Cholesteatoma

6. Middle Ear Exploration with Stapedotomy

7. Unilateral Cochlear Implantation

8. Bilateral Simultaneous Cochlear Implantation

9. Linear Incision BAHA

10. Skin Punch BAHA

11. Osia Bone Conduction Implant

12. Endolymphatic Sac Decompression

13. Labyrinthectomy

14. Lateral Temporal Bone Resection for External Auditory Canal Carcinoma

15. Combined Mastoid-Middle Cranial Fossa Repair of Temporal Bone CSF Leak

16. Middle Cranial Fossa for Superior Canal Dehiscence Repair

PEDIATRIC OTOLARYNGOLOGY

1. PE Tubes

2. Adenotonsillectomy

3. Tonsillectomy with Superior Segment Adenoidectomy

4. Frenulectomy

5. Microdirect Laryngoscopy and Rigid Bronchoscopy (MLB)

6. LASER Supraglottoplasty with Microdirect Laryngoscopy and Rigid Bronchoscopy

7. Cold Supraglottoplasty with Microdirect Laryngoscopy and Rigid Bronchoscopy

8. Sistrunk Procedure for Thyroglossal Duct Cyst Excision

RHINOLOGY & SINUS SURGERY

1. Full FESS

2. Endoscopic Septoplasty

3. Open Septoplasty

4. Bilateral Inferior Turbinate Reduction

5. Endoscopic Transphenoidal Pituitary Surgery

6. Transnasal Endoscopic Orbital Decompression

SLEEP SURGERY

1. Drug-Induced Sleep Endoscopy

2. Expansion Sphincter Palatopharyngoplasty with Tonsillectomy

3. Implantation of Hypoglossal Nerve Stimulator