DICTATION NUMBER
How to Track Op Notes

Our facility was having a hard time tracking completion of operative dictations. We implemented a practice whereby residents document the dictation number as an addendum to their brief op note so we could track completion of dictation and refer back for missing dictations. We review each record the day after surgery for verification. If there's no dictation number, we contact the surgeon. Our rate of dictated cases within 24 hours of surgery has gone from 60% to 100%. We find missing cases almost immediately since there is a reference number to give transcription.

Clara Kistner, RN
Michael E. DeBakey VA Medical Center
Houston, Texas
[email protected]