Ask Dr. Z

In your opinion, is this op note complete and acceptable? It appears to be truncated, and we are seeking your advice on how to educate the physician to improve his documentation that he states is complete. "OPERATIVE PROCEDURE: AV node ablation. PREOPERATIVE DIAGNOSIS: Atrial fibrillation, which is difficult to rate control. INDICATION FOR PROCEDURE: Briefly, the patient is a pleasant 66-year-old gentleman with persistent atrial fibrillation, which is difficult to rate control. The patient is undergoing AV node ablation along with pacemaker placement. PROCEDURAL DETAILS: After informed consent obtained, the patient was sedated and the right groin was prepped and draped in the usual fashion. An 8 French sheath was put in the right femoral vein, 8 French sheath was upgraded to a long Agilis sheath, and ThermoCool catheter was placed by this sheath into the AV node location. AV node ablation was performed at 35 w. Successful AV node ablation noted presence of paced beats. After ten minutes of observation, the AV node did not recover, so sheaths and caths were pulled. Successful ABL."