Elements

Yes

No

1) Date of surgery

2) Date of dictation

3) Patient identifiers

4) Name of surgeon and assistants

5) Name of anesthetist/anesthesiologist

6) Pre-operative diagnosis

7) Post-operative diagnosis

8) Procedure

9) Brief history of present illness (including relevant investigations)

0

1

2

3

4

No description

Preoperative course and indications described but some detail was lacking

Complete description of preoperative course and indications for procedure

Procedure

Elements

Yes

No

10) Type of anesthesia

11) Skin preparation and draping

12) Patient position

13) Method of abdominal access

14) Findings

0

1

2

3

4

No mention of findings

Findings stated but details/explanation lacking

Completely explains findings and notes unexpected findings

15) Technique of resection, including tissue mobilization

0

1

2

3

4

No description of mobilization or resection technique

Mobilization and resection techniques described but details regarding operative steps incomplete

Complete description of tissue mobilization and method of resection including instruments