Operative Report
An Operative report is a report written in a patient's medical record to document the details of a surgery. 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. In operative records there is given medications before and after surgery, there is also given patients data, medical history,(Hx , physical examination (PE), consent form , informed consent form, surgeons orders, anaesthesia note also written in operative report .) 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 ...
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Medical Record
The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite. The terms are used for the written (paper notes), physical (image films) and digital records that exist for each individual patient and for the body of information found therein. Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have le ...
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