An Operative report is a report written in a patient's
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 jurisdic ...
to document the details of a
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 pat ...
. 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 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 jurisdic ...
s, including the operative report. Standards for operative reports are set by the
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 cen ...
(AAAHC) and the
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 majori ...
on Accreditation of Healthcare Organizations (JCAHO)
References
External links
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Surgery
Health informatics