Standardized Operative Note

Checklist for Ovarian Cancer Operative Note Dictation

CLICK HERE for an online operative note generator

Please make sure to include the following data elements in your operative note.

  • Debulking Status – Primary vs. Interval Debulking
  • Staging Information – If available based on imaging (for example, at least stage IIIc for a patient with a biopsy-proven lesion of the omentum) Link to ovarian cancer staging
  • Surgery Type – Open/Robotic/Laparoscopic
  • Residual Disease Status – Please specify if:
    • No residual disease (R0 or no visible disease)
    • Optimally debulked (1-5 mm largest visible disease)
    • Optimally debulked (6-10 mm visible disease)
    • Sub-optimally debulked (>10 mm disease residual)
      • For suboptimally debulked patients, specify the size and location of residual disease
  • Surgical Complexity Scoring – Use the calculator below to get the score
    (Aletti GD, Dowdy SC, Podratz KC, Cliby WA. Relationship among surgical complexity, short-term morbidity, and overall survival in primary surgery for advanced ovarian cancer. Am J Obstet Gynecol. 2007;197(6):676.e1-e7.)

Checklist for Cervical Cancer Operative Note Dictation

CLICK HERE for an online operative note generator

Please make sure to include the following data elements in your operative note.

  • Staging Information – If available based on imaging Link to cervical cancer staging
  • Histology – Adenocarcinoma/Adenosquamous Carcinoma/Small Cell Cancer
  • Grade – 1/2/3
  • Surgery Type – Open/Robotic/Laparoscopic
  • Nodal Dissection – Full Nodes/Sentinel (include locations and site mapping details)
  • Ovaries – Removed/Not Removed/One Removed
  • Ovarian Transposition – Done/Not Done

Checklist for Endometrial Cancer Operative Note Dictation

CLICK HERE for an online operative note generator

Please make sure to include the following data elements in your operative note.

  • Surgery Type – Open/Robotic/Laparoscopic
  • Nodal Dissection – Full Nodes/Sentinel (include locations and site mapping details)
  • Pelvic Washings – Done/Not Done
  • Complications During Surgery