The dictated operative note is essential for the practice of oral and maxillofacial surgery. Unfortunately, the evidence indicates that the quality of dictated operative reports is poor. Important information is often omitted, In support of this was one study which showed that only 46% of items deemed important in the operative dictation were actually present in these documents (Edhemovic). This book was written to help readers dictate high quality operative notes.

Surveys have shown that few residency programs offer formal instruction on the content, structure, or importance of the operative report. Thus, residents leave their training programs to enter practice feeling inadequately prepared in this critical area.

Knowledge gaps in this area have important consequences for practitioners. The operative dictation is an important medico-legal document, and therefore it must be clear and complete.

Among the other consequences is reduced reimbursement or even denied claims for services provided when notes lack adequate descriptions and appropriate terminology. In one study of operative notes completed by residents, that authors wrote that nearly 30% of charges "would have been missed, delayed, or denied if the resident-dictated note was used to justify charges." (Novitsky)

Most surgeons don't realize the importance of properly dictating and coding an operative report until after residency when they've performed a substantial amount work and fail to receive reimbursement.

With increasing scrutiny of medical records by payers, it is more important than ever for the operative note to succinctly and clearly describe what was done to justify the codes that are submitted and maximize the chances of full reimbursement.