Operative report

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An Operative report is a report written in a patient's medical record to document the details of a surgery.[1] The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The information in the operative report includes preoperative and postoperative diagnosis and the condition of the patient after the surgery.[2] It is necessary for other healthcare professionals immediately attending the postoperative recovery of the patient.

In most American states and in many other jurisdictions patients have a right to receive a copy of their medical records, including the operative report. Standards for operative reports are set by the Accreditation Association for Ambulatory Health Care (AAAHC) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

References[edit]

  1. ^ Deutsch, Laurence M. (2001). Medical Records for Attorneys. ALI-ABA. p. 224. ISBN 0831808179 – via Google Books. 
  2. ^ Ireland, Patricia A. (2004). Hillcrest Medical Center: Beginning Medical Transcription Course. https://books.google.com/books?id=TifVUQO0JF4C: Cengage Learning. p. 13. ISBN 1401841082 – via Google Books. 

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