| The surgical report contains: | a detailed technical description of how the procedure was done |
| Surgical terminology includes: | terms related to anesthesia, names of surgical positions, instruments, and incisions, and suture techniques and materials. |
| An operative report may be called | an operative note, a surgical note, or a surgical report. |
| Each report must contain a: 1: | preoperative and postoperative diagnosis |
| Each report must contain a: 2 | the name of the operation or procedure |
| Each report must contain a: 3 | indications for the procedure |
| Each report must contain a: 4 | a description of findings and techniques |
| Each report must contain a: 5 | In addition, the report may include the patient's name, date of the procedure, and the surgeon's name.
Some include the case number, patient number, and the names of the assisting surgeons or physicians. |
| Common format for operative reports: 1: Preoperative diagnosis: 1: | Explains why the procedure is necessary.
It can be stated as a specific disease. |
| Common format for operative reports: 1: Preoperative diagnosis: 2
When the diagnosis is not clearly evident, the preoperative diagnosis is stated as a: | "rule out" or "suspected" diagnosis |
| Common format for operative reports: 1: Preoperative diagnosis: 3 | It must be present and must be related to the procedure performed |
| Common format for operative reports: 1: Preoperative diagnosis: 1-3 | congrats |
| Common format for operative reports: 2:
States the diagnosis after the operation or procedure is completed. It is a short descriptive title of what was actually found: | Postoperative diagnosis |
| Common format for operative reports: 2: Postoperative diagnosis: 1 | In all cases, the preoperative and postoperative diagnosis should be the same or closely related. |
| Common format for operative reports: 2: Postoperative diagnosis: 2 | both should be written in acceptable medical terms, without abbreviations or use of layman's terms. |
| Common format for operative reports: 2: Postoperative diagnosis: 3 | It is poor practice to simply write "SAME" for the postoperative diagnosis.
Examples:
Preoperative Diagnosis: Appendicitis
Postoperative Diagnosis: Appendicitis
Preoperative Diagnosis: Severe abdominal pain
Postoperative Diagnosis: Appendicitis |
| Common format for operative reports: 2: Postoperative diagnosis: 1-3 | congrats |
| Common format for operative reports: 3:
Describes the name of operation or procedure performed | Operation/Procedure |
| Common format for operative reports: 4:
gives the reason for the operation or procedure | Indications |
| Common format for operative reports: 5:
The longest and most technical part of t he operative report | Findings and Technique |
| Common format for operative reports: 5: Findings and Technique: A:
Tells how the patient was protected from feeling the pain of the operation. It gives t he type of anesthesia and how it was administered. The specific name of the anesthesia is usually included. | Type of anesthesia |
| Common format for operative reports: 5: Findings and Technique: B:
Describes how the patient was placed on the operating table: | Surgical position |
| Common format for operative reports: 5: Findings and Technique: C:
The surgical cut used to access parts of the body. It will describe the location, length, direction, and depth of the incision. | Incision |
| Common format for operative reports: 5: Findings and Technique: D
Describe what was done, how, and why it was done, and the patient's response. This is filled with names and sizes of instruments, suture materials and techniques, and conditions of the organs and tissues examined or removed. | Description |
| Common format for operative reports: 5: Findings and Technique: E:
Describe how the incision was closed, state that all surgical tools have been accounted for, and may include information about blood loss. | Closure |
| Common format for operative reports: 5: Findings and Technique: E: Closure: 1
An important part of the Findings and Techniques section is the: | sponge count |
| Common format for operative reports: 5: Findings and Technique: E: Closure: 2 | Every operative report must state that the surgeon can account for all surgical tools. |
| Common format for operative reports: 5: Findings and Technique: E: Closure: 3 | Prior to every procedure, a member of the surgical team counts item like sponges needles, and instruments.
After the procedure, these items are counted again to ensure that nothing was left inside the patient. |
| Common format for operative reports: 6:
Concerns the condition of the patient and is usually one or two sentences in length. | Patient condition |
| Format for patient name: | (Family/surname), (first name)
normal lang, capitalize first lettter of the name and not caps lock
PATIENT NAME: Ouddy, Busaba |
| Format for Date: | November 15 -- |
| Format for Name of Physician: | (First name), (surname), (title/specialization)
SURGEON: Henry D. Sousa, DPM
ANESTHESIOLOGIST: Jeffrey B. Morgan, MD |
| Operative report dissection notes: 1: | Do not start your sentence with a number particularly if it is anything measured. Always place an introductory phrase. |
| Operative report dissection notes: Preoperative and Postoperative Diagnosis: | the preoperative and postoperative diagnosis should be the same or closely related. Both should be written in acceptable medical terms, without abbreviations or use of layman's terms.
It is poor practice to simply write "SAME" for the postoperative diagnosis.
PREOPERATIVE DIAGNOSIS: Halluz Limibus, right foot.
POSTOPERATIVE DIAGNOSIS: Same (WRONG)
must be:
PREOPERATIVE DIAGNOSIS: Halluz limibus, right foot.
POSTOPERATIVE DIAGNOSIS: Halluz limibus, right foot. |
| TITLE OF: OPERATION/PROCEDURE | OPERATION PERFORMED: Cheilectomy, first metatarsophalangeal join, right foor. |
