What Are The Main Parts Of Operative Notes?

Operative Notes

Operative notes are created after a surgical procedure by the primary surgeon, who recalls the specifics of the process and dictates them into a narrative that is later typed out. Assessing surgical quality, invoicing, medicolegal concerns, and other secondary applications of operative notes, all require effective operative note documentation. Physicians can ensure accurate EHR documentation with the help of a competent medical transcription service.

What Is An Operative Note?

The operative report is arguably the most significant piece of information in a surgical chart. It serves as the formal record of what happened in the operation room. It must back up the patient’s need for treatment, detail each step of the surgery, and show the results of the operation. The most common document used to support claims for payment to the surgeon, surgical team, and facility is the operative report. Operative report documentation is also important for auditors and payers to confirm that the supporting paperwork matches all of the codes listed on the claim.

Four Main Parts Operative Note Documentation

An operative note contains four parts:

  • Heading: An operational report’s heading includes the following information
    • Facility Information: It includes the facility’s name, address, and the patient’s unique medical record number.
    • Patient information includes the person’s entire legal name, birthdate, age, and gender. This is because certain processes are age- and gender specific.
    • Date of Service: The day the operation was done.
    • Information about the surgery includes the primary surgeon’s name, the names of any co-surgeons, residents, or surgical assistants; the type of anesthesia used; the anesthesiologist’s or CRNA’s name; the use of any implants or specialized equipment (such as a microscope, robotic arms, etc.); complications; and the anticipated blood loss.
    • List of all eligible diagnoses to show medical need for pre- and post-operative care.
    • Procedure(s) Performed – A thorough list of the operation or operations.
  • History and surgery indication: The op report’s History/Indications for Operation section explains why the surgery is necessary and, if appropriate, what happened before it. The surgeon provides information about the patient’s past medical history relevant to the procedure, their family history relevant to the procedure, previous or unsuccessful therapies, how the disease or injury occurred, when it occurred, and for how long.
  • Body: It contains several aspects such as:
    • Description of the Procedure(s) – This part should include a description of every step of the procedure, from preparation to dressing and closure. Even if it is already noted in the Heading, if the surgery was performed bilaterally, both sides must be documented here in some way. The proper side must be recorded if something is done unilaterally.
    • The following elements are also recorded: the surgical technique (whether open or endoscopic), the placement of the implants or devices previously listed in the Heading, the use of robotic or microscopic assistance previously listed in the Heading, any specimens collected or frozen section procedures performed, intraoperative monitoring or testing, and any surgical procedures performed by another surgeon
    • The most crucial section of the operating report is the description of the procedure(s). This is when the fundamental principle of a coder , “NOT DOCUMENTED, NOT DONE,” comes into play. If a technique is not included here, auditors or payers may choose not to reimburse for it or may choose to recover a prior payment for it.
    • Coding must come from this part as well as from the Heading’s procedure listings. The heading’s procedures should just serve as a coder’s check list for what to look for in the operative report’s body. The surgeon needs to be contacted for confirmation and potential correction if the coder discovers a procedure is missing, bilateral documentation is missing, or there are any other inconsistencies between the heading and the body.
  • Findings and follow up
    • Summarize the surgical results in your summary of findings.
    • Complications – Any complications, or lack thereof, must be noted here.
    • Future Procedures or Follow-Up Care – The surgeon should record any upcoming (staged) procedures to ensure accurate modifier assignment. Indications from follow-up or additional screenings should also be included here.

General Principles of Operative Notes Documentation

  • A member of the operating team is required to complete all operations notes right away following an operation (either be handwritten or typed). All post-operative notes should be included as the most recent entry in the patient’s current medical records, and they should travel with the patient to recovery and subsequently the ward. It is crucial to ensure that the operation note is written concisely and properly, including the post-operative instructions.
  • The intra-operative findings, including any and all diseases, should be clearly and concisely stated as part of the surgical diagnosis. A reference copy of any photographs taken during the process should be included with the operation note.
  • The processes taken in the operation, from the first skin incision through closure, should all be accurately described in the technique as it is performed. This could include any pertinent vessel ligations, implants or prostheses used, tissue removals, and alterations in specified anatomical structures.
  • The closure should be documented along with the material(s) used and the closed layers, such as fascia, fat, and skin. Any intraoperative complications should be accurately reported, together with any specimens obtained and the estimated blood loss (recorded in mls).
  • To guarantee proper post-operative care, post-operative instructions should be carefully documented to include any specific plans that must be followed after the treatment. This covers any drugs to be administered, whether the patient is able to eat and drink, whether they may be sent home, and any required follow-up activities (including dressing changes or suture removal)
  • After the operation note has been written, it should be signed, dated, and the signing doctor’s name, grade, and registration number should be included.
Learn more: Four Key Reasons Why Medical Transcription Is Important Today

Like other medical reports, operative report documentation is a significant document in the EHR. These reports, which offer thorough health information about your patients, can be shared with other healthcare professionals and organizations including laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, etc. Partner with a reputable medical transcription company that can turn surgeon dictations into correct surgical notes.

Julie Clements

About Julie Clements

Joined the MOS team in March of 2008. Julie Clements has background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort. Julie was instrumental in the creation of the medical record review division (and new web site); and has especially grown this division along with data conversion of all kinds.
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