July 20, 2023
When acting as an assistant surgeon, should I dictate a separate operative note?
No. In a scenario with a primary and assistant surgeon, only the primary surgical dictates the operative note. Importantly, in that note, the specific role of the assistant must be documented. This should be more specific then, Dr. Jones assisted in a complex surgery. The specific activities performed must be documented. For example, Dr. Jones assisted with the exposure, vessel clamping , anastomoses of the inflow and outflow vessels.
*This response is based on the best information available as of 07/20/23.