Help with Dictation

[Pharynx Freak]

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I'm a new ENT resident and have been asked to dictate many daunting operative reports to include total laryngectomies with free flap reconstruction and bilateral MRND, WLE of melanoma with SLNB and MRND & superficial parotidectomy, and the like. While I've given it my best effort, it would be nice to have a pre-formed "dictation template" to start from. Anyone out there have any idea if such a thing exists for ENT-specific surgeries? Thank you in advance.

 

[OtoHNS]

I'm a new ENT resident and have been asked to dictate many daunting operative reports to include total laryngectomies with free flap reconstruction and bilateral MRND, WLE of melanoma with SLNB and MRND & superficial parotidectomy, and the like. While I've given it my best effort, it would be nice to have a pre-formed "dictation template" to start from. Anyone out there have any idea if such a thing exists for ENT-specific surgeries? Thank you in advance.

I typically dictate the following for any surgery:

My name and ID number
Pt name/MRN
Date of surgery/Date of dictation
Attending surgeon
Assistant(s) (aka residents/med studs/PAs/NPs)
Procedure(s) performed
Pre-procedure diagnoses (include TNM stage if appropriate)
Post-procedure diagnoses (ditto)
Anesthesia type
EBL
Drains and tubes
Pathology specimen(s) sent
Indications for procedure
Operative findings
Detailed description of procedure

The most important parts of the dictation in my opinion are the indications and findings. That's what I'm going to look at (as well as what procedures were done) when I read an operative report. If you are unclear what to say for these sections, ask your attending. I would avoid getting bogged down describing every structure that was bovied and every stitch that was thrown.

Also, as an aside, I find it pretty lame that your program requires new residents to dictate complex procedures. They are basically asking to get crappy operative reports (no offense, I'd have done the same if asked of me as a PGY2). In my program, the resident surgeon (typically a 4 or 5 for big cancer cases) would dictate. PGY-2s would dictate their cases, ie tubes, tonsils, DLs, etc.

 

[resxn]

I typically dictate the following for any surgery:

My name and ID number
Pt name/MRN
Date of surgery/Date of dictation
Attending surgeon
Assistant(s) (aka residents/med studs/PAs/NPs)
Procedure(s) performed
Pre-procedure diagnoses (include TNM stage if appropriate)
Post-procedure diagnoses (ditto)
Anesthesia type
EBL
Drains and tubes
Pathology specimen(s) sent
Indications for procedure
Operative findings
Detailed description of procedure

The most important parts of the dictation in my opinion are the indications and findings. That's what I'm going to look at (as well as what procedures were done) when I read an operative report. If you are unclear what to say for these sections, ask your attending. I would avoid getting bogged down describing every structure that was bovied and every stitch that was thrown.

Also, as an aside, I find it pretty lame that your program requires new residents to dictate complex procedures. They are basically asking to get crappy operative reports (no offense, I'd have done the same if asked of me as a PGY2). In my program, the resident surgeon (typically a 4 or 5 for big cancer cases) would dictate. PGY-2s would dictate their cases, ie tubes, tonsils, DLs, etc.

I agree with everything above, but I disagree with the most important parts of the dictation. Having served as an expert witness on malpractice cases about a dozen times now, the dictation of the technique used is the single most important thing and the most important of that is what studies (CT) were available throughout the duration of the case or adjuvant equipment was utilized (nerve monitor, etc). Indications is #2. As a surgeon reviewing a case for my own information, I agree with OtoHNS, but dictations are for #1 billing and #2 CYA. A distant 3rd is for future care which is where the findings are very useful.

 

[OtoHNS]

I agree with everything above, but I disagree with the most important parts of the dictation. Having served as an expert witness on malpractice cases about a dozen times now, the dictation of the technique used is the single most important thing and the most important of that is what studies (CT) were available throughout the duration of the case or adjuvant equipment was utilized (nerve monitor, etc). Indications is #2. As a surgeon reviewing a case for my own information, I agree with OtoHNS, but dictations are for #1 billing and #2 CYA. A distant 3rd is for future care which is where the findings are very useful.

Awesome post, thanks.

Regarding the CT availability, I definitely do not routinely mention that. Though if I use image guidance for a FESS, I would say that for sure.

It sounds to me like CT availability would mostly be an issue for cases involving skull base or orbit violation during sinus surgery. Any other examples where you've seen this come into play during a med mal case?

 

[resxn]

Awesome post, thanks.

Regarding the CT availability, I definitely do not routinely mention that. Though if I use image guidance for a FESS, I would say that for sure.

It sounds to me like CT availability would mostly be an issue for cases involving skull base or orbit violation during sinus surgery. Any other examples where you've seen this come into play during a med mal case?

Here's the classic case where there's really no defense and a bit over-the-top obvious. 76yo man presents to ENT clinic to a 1st year attending (no fellowship, just finished residency 6 months prior) for nasal polyp. Polyp is obvious on exam in the clinic, unilateral L side hangs below middle turb but not below inf turb. No significant symptoms other than nasal obstruction. No h/o CRS or other problems. No previous h/o significant trauma to face. MD takes pt to the OR for polypectomy. Films not hanging in the OR. Op report indicates no complications for procedure--routine polypectomy, no ethmoidectomy, only max antrostomy as polyp seemed to be coming from infundibulum. CT not hanging in OR. Pt had CSF leak discovered post-op day #1. Path showed brain. Now here's why this is obvious: reason CT wasn't in room was because MD never got CT. It wasn't a polyp it was a myelomeningocoele. Pt repaired at university hospital endoscopically and did well. MD settled out of court for undisclosed amount for negligence (failure to properly diagnose) and surgical misadventure charges.

Less obvious case, but essentially same thing. 34yo mother of two presents to ENT for CRS. CT obtained demonstrating significant B maxillary and ethmoid disease. Failed maximal medical therapy. Good informed consent documented, pt went to OR. ENT grabbed CD of CT scan and brought to OR to load on laptop available for CT review. Laptop crashed and CD couldn't load. No other laptops brought in. MD decided not to ask for CT to be printed out and proceeded with B max antrostomies and B anterior ethmoids only--decided against post ethmoid since films not available. Pt had CSF leak proven by beta-transferrin 1 week out. All appropriate steps taken to diagnose and treat leak. Endoscopic closure #1 failed at tertiary referral center due to granulation tissue at site of repair. Repeat procedure 10 days later effective. Pt suffered no long-term disability. However, pt sued first physician for surgical misadventure and compensation of lost wages and medical bills despite informed consent. Plaintiff's atty argued that although CSF leak is known complication, it could have been avoided if CT had been available for review. Expert witness for plaintiff agreed with this argument. Defense expert witness (me) pointed out that there are no studies demonstrating that the presence of films in room has shown to decrease risk of CSF leak. However, accepted standard of care in the metro area in which this case occurred was to have films in room. Jury decided case on behalf of plaintiff for $78,000 because MD decided not to proceed with post ethmoid since films weren't available and this indicated to them that films are useful in the OR.

Standard of care is no longer defined by the local medical practice. It is now defined nationally. A medmal lawyer will tell you outright that FESS without films in the room is an automatic win these days for the plaintiff if there are damages and causation. Fairly easy to prove in these situations.

OtoHNS, I've not been involved in or reviewed any cases where the presence of films was an issue in a sinus medmal where skull base or orbit were not the complication. Other than hemorrhage ultimately causing damages in a FESS case I can't think of where films would be an issue. Perhaps failure to biopsy the correct lesion within a nose and thereby missing the diagnosis of an intranasal malignancy? That's another possibility I suppose.

Have all films available and dictate that all films were visible throughout the case for review as needed, regardless. Even in a state with tort reform, there's no such thing as too much CYA.

 

[OtoHNS]

Interesting and informative, thanks.

I agree case 1 is obvious and I'd personally never do any sinus case without looking at a scan 1st.

Case 2 is interesting. I'd argue that having the scan available can be helpful but it's not going to tell you where you are in the nose (image guidance excepted of course). I always look at the scan before any sinus case to get an idea of the contours of the skull base and lamina as well as any other distinctive anatomy but I'd say it would be rare that I'd need to look at the scan repeatedly during the case. It does sound like the defendant screwed himself by deciding not to do the posterior ethmoids. Was this an older surgeon?

I wonder when someone is going to lose a lawsuit because they didn't use image guidance for a routine sinus case. I'm sure it's coming if it hasn't already...

 

[resxn]

Case 2 is interesting. I'd argue that having the scan available can be helpful but it's not going to tell you where you are in the nose (image guidance excepted of course).

Agree, but here's how the questioning goes in court:
Lawyer: Did you have the films in the OR?
MD: No. I reviewed them in my office prior to surgery and felt comfortable with the anatomy and felt they weren't necessary for this case. If I became uncomfortable, I could easily have office staff bring them to the OR for my review. And in this case, I didn't feel uncomfortable with the anatomy or progression of the surgery.
Lawyer: If the films were available for you to review, and understanding that the pt had an asymmetrical Keros classification, is there a chance that reviewing them in the OR may have helped prevent a CSF leak?
MD: Like I said, I don't think it would have helped in this particular case.
Lawyer: But, is there a chance it could have.
MD: Sure, there's always a chance, but in this. . .
Lawyer: Thank you, doctor, no further questions

I always look at the scan before any sinus case to get an idea of the contours of the skull base and lamina as well as any other distinctive anatomy but I'd say it would be rare that I'd need to look at the scan repeatedly during the case. It does sound like the defendant screwed himself by deciding not to do the posterior ethmoids. Was this an older surgeon?

Surgeon was in his early 40's. Had over 450 ethmoidectomies under his belt since residency. Personally, I know he's never had another CSF leak, but this was not discoverable in the trial. He didn't screw himself by not doing the post ethmoids in this case. He screwed himself because he didn't have films. Had he had them present, the CSF leak would have been just one of those things that happens. They couldn't blame surgical misadventure because the films would have allowed him to defend his understanding of the pt's anatomy.

I wonder when someone is going to lose a lawsuit because they didn't use image guidance for a routine sinus case. I'm sure it's coming if it hasn't already...

Richard Orlandi gives a talk almost yearly on whether IGS is the standard of care in FESS. Right now, it's not considered the standard of care even for revision FESS, but that will likely change in the next 2-5 years especially as ACO's are developed. On the other hand, those who opine on this stuff don't think it will ever be the standard of care for a virgin FESS that has no signs of bony landmark destruction on standard CT. Ultimately, it may when landmarks are not well-defined on the typical CT, but this is controversial and there is not much literature on it yet.

 

[neutropeniaboy]

I always have films available; never do I dictate their presence (except in image-guidance cases because that fulfills a billing requirement). It's unnecessary to mention them in the dictation. However, I must admit that it's a loser if you get a complication and don't have them (despite the fact that the presence or absence of films in no way predicts the incidence of complications).

 

[neutropeniaboy]

I'm a new ENT resident and have been asked to dictate many daunting operative reports to include total laryngectomies with free flap reconstruction and bilateral MRND, WLE of melanoma with SLNB and MRND & superficial parotidectomy, and the like. While I've given it my best effort, it would be nice to have a pre-formed "dictation template" to start from. Anyone out there have any idea if such a thing exists for ENT-specific surgeries? Thank you in advance.

Yeah, had to do that myself. It's a learning process. However, it made me better at streamlining my own dictations.

I've basically got the same thing for each procedure I do. Each contains the necessary mumbo-jumbo to satisfy the auditors and the lawyers. I have a findings section, which is strictly for my reference to help me recall the patient's course.

 

[resxn]

I always have films available; never do I dictate their presence (except in image-guidance cases because that fulfills a billing requirement). It's unnecessary to mention them in the dictation. However, I must admit that it's a loser if you get a complication and don't have them (despite the fact that the presence or absence of films in no way predicts the incidence of complications).

NPB, given that it's a loser not to have them, let's say there was a complication and you didn't dictate that they were available for review, how do you demonstrate that they were in the room? Nursing records don't record it. I guess if you're on a PACS system, I assume they could pull up the log in records but if the films aren't in PACS, then what?

 

[neutropeniaboy]

NPB, given that it's a loser not to have them, let's say there was a complication and you didn't dictate that they were available for review, how do you demonstrate that they were in the room? Nursing records don't record it. I guess if you're on a PACS system, I assume they could pull up the log in records but if the films aren't in PACS, then what?

I'll simply say this on the issue. It may be the standard of care to have films in the room, but films in the room don't prevent complications. Furthermore, I don't think it's necessary to dictate that they are present. In my facility, the nursing logs indicate whether films are present or not. Regardless, if there is not written indication of whether films were present, it certainly will come out in discovery.