If you are a physician who is about to perform a certain surgery on a patient, no matter how minor or major it is, you are required to make a valid report samples on every details of the surgery. Such document is called an operative report. Before writing, it is appropriate to follow its proper report format, which you will see as we go through this article. You may also see Report Examples.
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Operative Report Template
Post Operative Report Template
Although other people may think that report writing is an easy task, it is a skill that takes so much time to develop and improve because you will need to write and organize the details as clearly and concisely as you can to make sure that the reader is able to understand the contents easily. You may also see Report Sample Doc.
What Is an Operative Report?
The key to writing an effective operative report is to understand its objectives/purpose rather than just writing all the details that goes in each specific section. But first, we need to understand what an operative report is.
An operative report is a document that contains all the essential medical record of a patient and outlines the details of the the surgical procedure. All relevant details are usually laid out right after the surgery and is then written down into the patient’s medical record. If you will have to write a daily report on surgical procedures performed in your facility, feel free to browse our vast library of daily report templates in our website.
Writing an Operative Report
When writing an operative report, a lot of coders prefer using medical report templates for convenience. So, once you have all the details of the surgical procedure, you will have to input them in the appropriate fields or section.
- Write down the demographic information, such as the name, age, and medical records of the patient, date the procedure is performed, names of the surgeons and anesthesiologist, and type of anesthesia used.
- Take note of the pre- and post-operative diagnosis.
- Review the general statement of the surgical procedure to be performed on the patient.
- Take note of any complications that took place during the procedure.
- Identify the pathology specimen, such as the type of tissue removed.
- Check for significant blood loss or any clinical indicators relevant to the patient’s treatment and/or diagnosis.
- Write down a quick summary of the surgical details.
- Double check the information.
Annual Operating Report
Why to Choose our Operative Report Templates
Creating new documents for every surgical procedures can be a total waste of the time and money. So instead of wasting your effort, visit our website, Template.net, and choose from our collection of templates provided above. You can easily and conveniently download and edit our templates to match your personal purpose. What is even great is that all of our templates are well thought and professionally written by experts to guarantee satisfaction because that is what drives us.
Before you leave this article, do not also hesitate to check out our annual report templates in our website.