Chapter 32

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

All rights reserved. No part of this publication which includes all images and diagrams may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the authors, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law.

Westmead Eye Manual
This invaluable open-source textbook for eye care professionals summarises the steps ophthalmologists need to perform when examining a patient.


Website by WebInjection