After each surgery that is performed, the head surgeon is required to write or dictate an operative report. Most of the time this will be done by a professional medical transcriptionists who have been specially trained to write in the language of medicine and transcribe these operative reports.
Although this process should be only conducted by a professional, it may be wise to understand how it works. Below are some instructions on how to write an operative report.
Although this process should be only conducted by a professional, it may be wise to understand how it works. Below are some instructions on how to write an operative report.
- Step one. The first thing that should be done is type the patient's name and their individual record number on the top of the page. You should also include their date of birth. However the requirements for each hospital are different.
- Step two. You should then state the type of operation that was performed. A blank line should be left between each piece of information that is stated. A reason for the operation should also be stated.
- Step three. The next thing that you should write should be written on a new paragraph by leaving a line between the last paragraph and the new one to be written. This current paragraph should mention the diagnosis that was concluded before the operation. The next paragraph should state the post operative diagnosis.
- Step four. The next section should be written under the heading of 'Procedure in Detail'. This section should be completed by writing out every step of the operation in complete detail. This section should also include any problems that were encountered. The instrument count should also be included.
- Step five. You should finish off the report with a closing statement about the final stages of the surgery. This should include final steps and any post operative information. Your report should then be thoroughly proof read and edited.