Chaim Colen, M.D., Ph.D., Christopher Gayer, M.D., Ph.D., and John Lam, M.D. have written what I believe is an extremely important book for surgeons, especially those in training. Operative Flash-Dictation: General Surgery provides information on how to dictate the best possible operative reports by providing an outline and a step-by-step approach for each of the major types of general surgery procedures. Residents can learn a great deal from doing proper operative dictations, and it is very important for optimal patient care.

Operative dictations should be performed, whenever possible, immediately following the surgery. Otherwise, much of the important detail can be quickly lost. The surgical dictation should include the indications for surgery, the important findings at the time of surgery, and the steps of the actual surgery performed. In addition, any problems encountered should be described in detail, as well as any part of the surgery that is unusual. The reasons for any deviations from the norm must be clearly noted. The dictation should also provide information on use of any drains, estimated blood loss, and fluids given. How the patient tolerated the surgery should also be noted, with careful attention to any deviations from normal. Providing the CPT codes for each surgical procedure can be extremely helpful for future reference in the billing office.

Having a timely and thorough operative report available for review can be indispensable, especially if repeat surgery may be required or postoperative problems arise. In addition, having been a “defense expert” on many malpractice cases, I have found that a good operative dictation is invaluable for protecting the surgeon. In particular, documenting that the risks of the surgery and alternative therapy were discussed with the patient and/or family or guardian is critical medicolegally.

I am honored to have been invited to write this foreword by one of the authors, Christopher Gayer, MD, PhD. Dr. Gayer has been an outstanding general surgery resident in the Wayne State University program and has elected to do an additional two years of training in pediatric surgery beginning July 1, 2010.

Robert F. Wilson, MD, FACS

Professor of Surgery

Wayne State University School of Medicine