Hospitals and clinics are not different from any business. It also needs documentation and reporting, particularly if they have surgeries and other high-risk procedures. Operation reports are very tricky to write. It needs to record all the data and details of the surgery so you won’t have a hard time monitoring the patients’ condition. As a medical practitioner, how would you write an organized and informative operation report? Scroll out our downloadable operation report templates below and learn about this topic in this article.
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What Is an Operation Report?
An operation report is a written document that consists of the detail of the patients’ surgery. It is written immediately after the operation procedure or other high-risk procedure. It consists of preoperative and postoperative diagnosis and the state of the patients after the surgical procedures. It is needed for health workers to record and document every detail to monitor the patients’ recovery. According to the Yale School of Medicine, if the operation report is not placed in the medical record immediately after the operation due to filling delay or transcription, then there must be an operation progress note placed in the medical record after the surgery. It is necessary to prevent pertinent information for anyone required to attend to the patient.
What are the Two Types of Surgery?
There are two kinds of surgical procedures. It is open surgery and minimally invasive surgery. Open surgery is a method where a surgeon will cut the skin and tissues of the patient. In this way, the surgeon can have a full view of the structures and organs involved. While minimally invasive surgery a surgery that does not need a large incision.
How to Write an Operation Note?
Writing an operation note is very vital. It is a document that consists of the patients’ medical records and finding after the surgery. That is why you need to organize everything before writing. Poor operation notes or reports can jeopardize patient care and prejudice in medicolegal cases. Here are some tips that can help you:
Step 1: Write the Details of the Operation
State the date and time of the operation. Be precise and clear. State the type of surgery and the specific location of the body. Also, don’t forget to include the type of anesthesia and whether it is an emergency or not. You also have to include the names of the attending medical practitioners. They are the surgeon, anesthetist, and assistants and include their roles in the operation. And, don’t forget the name of the patient and the details of their preparation.
Step 2: Give the Diagnosis or Findings
Write detailed findings and diagnosis of the patients’ health after the surgery. You also have to include if there are complications or any infections. In this way, the attending medical practitioner will know how to handle and approach the patient. Also, state if the patient needs to undergo other procedures and indicate why.
Step 3: Follow the Procedure of the Operation
Write a step by step documentation of the operation procedure. Including major structures preserved, techniques used, radiological images, and even microbiological specimens. You can use diagrams to specify and illustrate your operation report properly. You also have to document the removed tissue or bodily fluids during the operation. Also, don’t forget to include the type, size, and serial numbers of prostheses and sutures used. And lastly, include the closure technique used.
Step 4: Write the Postoperative Care Instruction
Write the postoperative instructions. Write it step by step to make it more understandable. These postoperative instructions will help your patients ease their discomfort and heal their wounds easily. Also, it is a great help in reducing postoperative complications after high-risk surgery.
When must an operation report be done?
An operation report is usually available right after the operational procedure or surgery. In case the operational report is not yet released and written after the surgery for some reason, there should be a note that indicates that it is still in progress.
How can I get an operation report?
You can go to your doctor. He or she may have a hard copy of your operation report in his or her office. Also, you may go to the hospital’s medical records department where your operation was performed. They have all the patients’ medical records, and you can be sure that they have all your records filed.
Who can write an operation report?
Although there are so many medical practitioners present during the operation, only one person is allowed and obligated to write an operation report. Only assistant surgeons can write or dictate an operation report.
How long does a regular surgery take?
Any surgery, emergency or not, take time to finish. Many surgical procedures take only two to three hours. However, it depends on what kind of procedure the surgeons are using. Most of the time, emergency and other high-risk operations take too long than usual. However, surgeons take many steps to ensure the safety of the patients.
Reports are everywhere. Even in the medical world, reports play a vital role. It helps in tracking and monitoring the patient’s state and health. That is why it is needed to have an organized and precise operation report to provide all the patients’ needs. If you find it hard to create a good operation note or document, our operation report templates are here for you! Download now!
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