Operative Report
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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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Surgery
Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pathological condition such as a disease or injury, to help improve bodily function, appearance, or to repair unwanted ruptured areas. The act of performing surgery may be called a surgical procedure, operation, or simply "surgery". In this context, the verb "operate" means to perform surgery. The adjective surgical means pertaining to surgery; e.g. surgical instruments or surgical nurse. The person or subject on which the surgery is performed can be a person or an animal. A surgeon is a person who practices surgery and a surgeon's assistant is a person who practices surgical assistance. A surgical team is made up of the surgeon, the surgeon's assistant, an anaesthetist, a circulating nurse and a surgical technologist. Surgery usually spa ...
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Accreditation Association For Ambulatory Health Care
The Accreditation Association for Ambulatory Health Care (AAAHC), founded in 1979, is an American organization which accredits ambulatory health care organizations, including ambulatory surgery centers, office-based surgery centers, endoscopy centers, and college student health centers, as well as health plans, such as health maintenance organizations and preferred provider organizations. AAAHC has been granted "deemed status" to certify ambulatory surgery centers for Medicare by the Centers for Medicare and Medicaid Services. In 2009, the AAAHC added the Medical home to the types of organizations that it accredits. It offers on-site surveys for organizations seeking Medical Home accreditation or certification. The AAAHC survey model is one of cooperation and education. It is unique in offering accreditation surveys that are conducted by professionals who are actively involved in ambulatory care and have first-hand understanding of the specific issues facing the facilities the ...
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Joint Commission
The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization that accredits more than 22,000 US health care organizations and programs. The international branch accredits medical services from around the world. A majority of US state governments recognize Joint Commission accreditation as a condition of licensure for the receipt of Medicaid and Medicare reimbursements. The Joint Commission is based in the Chicago suburb of Oakbrook Terrace, Illinois. History The Joint Commission was formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and previous to that the Joint Commission on Accreditation of Hospitals (JCAH). The Joint Commission was renamed The Joint Commission on Accreditation of Hospitals in 1951, but it was not until 1965, when the federal government decided that a hospital meeting Joint Commission accreditation met the Medicare Conditions of Participation, that accreditation had any official impact. However, Se ...
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Surgery
Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pathological condition such as a disease or injury, to help improve bodily function, appearance, or to repair unwanted ruptured areas. The act of performing surgery may be called a surgical procedure, operation, or simply "surgery". In this context, the verb "operate" means to perform surgery. The adjective surgical means pertaining to surgery; e.g. surgical instruments or surgical nurse. The person or subject on which the surgery is performed can be a person or an animal. A surgeon is a person who practices surgery and a surgeon's assistant is a person who practices surgical assistance. A surgical team is made up of the surgeon, the surgeon's assistant, an anaesthetist, a circulating nurse and a surgical technologist. Surgery usually spa ...
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