An operative report should be dedicated or written in the medical record immediately after surgery. It should contain a description of the findings the technical procedures used, the specimens removed, the preoperative and postoperative diagnosis or the diagnoses, the type of operation performed, and the name of the primary surgeon and any assistants. If the postoperative diagnosis is the same as the preoperative diagnosis, repeat it exactly. The body of the report is a narrative of the procedure and findings and contains the type of anesthetic, incision, instruments used, drains, packs, closure, sponge count, tissue removed or altered, blood loss and replacement, wound status, complications or unusual events, and condition of patient on leaving the surgical area. The completed operative report should be authenticated by the surgeon and filed in the medical record as soon as possible after surgery. When there is a filing delay, a comprehensive operative progress note should be entered in the medical record immediately after surgery to provide pertinent information for other physicians who may be attending the patient.
See Figure II-6 for an example of an operative report. The first paragraph is long, but this is how many surgeons dictated their operative records. Some hospitals may require that surgeons separate the report into subheadings, such as anesthesia, incision, findings, and so on.
FigureII-6 Operative report, typed in indented format with the body of the report done in one or two long paragraphs.