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. 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

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

* {{surgery-stub Surgery Health informatics