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 | |||