How to Write a Postoperative Report
Postoperative reports provide a step-by-step account of exactly what occurred during a surgical procedure. The report includes every detail from the reason for the procedure to how well the patient handled the procedure. Patients have the right to obtain a copy of the report. The reports are used for insurance reasons, hospital records and personal reasons. A surgeon present during the operation must dictate the report and send it off to be transcribed.
Instructions
Identify the patient. The first line of the report should identify the patient. Patients are identified by name, date of birth and medical record number.
Identify the surgery date and physician involved in the procedure. The date of admission and surgery should be indicated along with the discharge date -- if known. The surgeons should also be listed. Include the attending surgeon as well as residents and medical students who were present.
Indicate the preoperative diagnosis. The diagnosis is the reason why the surgery is being performed.
Provide the name of the procedure. Describe the procedure in a few words.
Take note of the type of anesthesia used. Indicate the use of any hemostasis -- means of preventing blood flow -- as well.
Describe intraoperative findings and indicate the reasons why the surgery was performed.
List the steps of the procedure. Describe, in detail, exactly what happened during the procedure. Begin with marking of the surgical site and end with suturing.
Document patient aftercare. Indicate how the patient handled the surgery and postoperative instructions given to the patient and caretakers.
Dictate the report.
Sign the operative report. The operative report should be read over and signed by the attending surgeon.