"My attending wants me to dictate the case we did together. I have no idea what to say. Are there any resources to help me?"
There is a lot of learning and mistakes that go into dictations. Some attendings won't have you dictate because its a legal record and its more work for them to correct your mistakes, but you NEED to learn. And its best to start as early as possible.
While there may not be a standard script at your stage, you will develop one for the routine operations you do as an attending.
Some tips:
Identifying information: Start off by identifying yourself and spelling your name. "This is Dr. Kimberli S. Cox, spelled K-I-M.., dictating an operative report on John Q. Public, Medical record number xxxx, on (date).
Details about the Case (similar to what you would write in your brief operative summary)
Attending: xxxxx
Assistants: spell all names, give titles or PGY #s
Procedure: name of operation and/or procedures performed; since this can be used for billing, make sure you name anything billable (ask if you don't know)
Anesthesia: general vs local, regional blocks
Estimated Blood Loss: (get from anesthesia)
IV Fluids: ditto
Urine output: ditto, if measured
Specimens: whatever you took out
Drains: if any
Complications: if any
Then go on to the
Indications for the procedure. For example:
Jane Q. Public is a 55 year old female who presented to Hospital X with a Class 5 Mammography and a right breast stereotactic biopsy postive for invasive ductal carcinoma. After a discussion with the patient regarding her treatment options, including right partial mastectomy with sentinel lymph node biopsy and possible axillary dissection versus Simple Mastectomy with Axillary staging, the patient has given her consent for the former. She understands the risks, benefits and alternative and freely gives signed and verbal consent.
Procedure:
Here you state what you actually did. My example would be something like:
The patient was brought to the operating room, properly identified and placed in a supine postion on the operating room table with her right arm extended at 90 degrees. A time-out was performed in which the patient, procedure and laterality were confirmed by the attending surgeon and anesthesiologist. She had previously undergone injection with Technetium-99 in the Nuclear Medicine Department of Hospital X as well as mammographic-guided wire localization in the Women's Imaging Center. These were tolerated without complications.
After satisfactory induction of general endotracheal anesthesia, bilateral sequential compression devices were placed on the patient and a Foley bladder catheter inserted. The localizing wires were snipped short to prevent dislodgement. The Neo-probe 2000 was used to mark an area of radioactivity around the right breast. The maximum in-vivo count was xxx. Five ccs of methylene blue was injected intradermally into the right breast. Her right chest was then prepped with Betadine and draped in the usual sterile fashion. Using the mamographic images provided as guidance, a skin incision was made at xxx o' clock using a number 15 blade. The deeper tissues were then divided using Bovie electrocautery....
blal blah blah
Then at the end, always include some statement such as:
At the end of the procedure, all sponge and instrument counts were correct times two per OR nursing staff. The wound was cleansed, dried and dressed with Steri-strips and a sterile occlusive dressing. The patient was awakened from anesthesia and transported to the recovery room in stable condition (provided that is true). Dr. Attending was present and scrubbed for the entire/significant/difficult portions of the procedure (whatever is true).
The restate your name, the patient's name and med rec number, the date and the attending you are dictating for. If they give you a confirmation number, always write it down, so if it comes up that you "didn't do the dictation" you have some backup to show.
There are books with some sample dictations and you can probably find some on-line as well. Here's one thats pretty popular and I believe there is also an electronic version as well:
http://www.amazon.com/Operative-Dict.../dp/0387955895
As always, make sure that you did what you are dictating - ie, if there are deviations from standard, you must mention these. Ask the attending if there are things you don't need to mention (ie, if the initial instrument count was incorrect, but then you found the needle on the floor, you don't necessarily need to comment on that. It only provides fodder for any potential lawsuits later and doesn;t change the outcome of the case.).
Eventually, what you do will become standard in your mind and practice - ie, the same way every time, so your dictations will become rote.