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level: operative report

Questions and Answers List

level questions: operative report

QuestionAnswer
The surgical report contains:a detailed technical description of how the procedure was done
Surgical terminology includes:terms related to anesthesia, names of surgical positions, instruments, and incisions, and suture techniques and materials.
An operative report may be calledan operative note, a surgical note, or a surgical report.
Each report must contain a: 1:preoperative and postoperative diagnosis
Each report must contain a: 2the name of the operation or procedure
Each report must contain a: 3indications for the procedure
Each report must contain a: 4a description of findings and techniques
Each report must contain a: 5In addition, the report may include the patient's name, date of the procedure, and the surgeon's name. Some include the case number, patient number, and the names of the assisting surgeons or physicians.
Common format for operative reports: 1: Preoperative diagnosis: 1:Explains why the procedure is necessary. It can be stated as a specific disease.
Common format for operative reports: 1: Preoperative diagnosis: 2 When the diagnosis is not clearly evident, the preoperative diagnosis is stated as a:"rule out" or "suspected" diagnosis
Common format for operative reports: 1: Preoperative diagnosis: 3It must be present and must be related to the procedure performed
Common format for operative reports: 1: Preoperative diagnosis: 1-3congrats
Common format for operative reports: 2: States the diagnosis after the operation or procedure is completed. It is a short descriptive title of what was actually found:Postoperative diagnosis
Common format for operative reports: 2: Postoperative diagnosis: 1In all cases, the preoperative and postoperative diagnosis should be the same or closely related.
Common format for operative reports: 2: Postoperative diagnosis: 2both should be written in acceptable medical terms, without abbreviations or use of layman's terms.
Common format for operative reports: 2: Postoperative diagnosis: 3It is poor practice to simply write "SAME" for the postoperative diagnosis. Examples: Preoperative Diagnosis: Appendicitis Postoperative Diagnosis: Appendicitis Preoperative Diagnosis: Severe abdominal pain Postoperative Diagnosis: Appendicitis
Common format for operative reports: 2: Postoperative diagnosis: 1-3congrats
Common format for operative reports: 3: Describes the name of operation or procedure performedOperation/Procedure
Common format for operative reports: 4: gives the reason for the operation or procedureIndications
Common format for operative reports: 5: The longest and most technical part of t he operative reportFindings and Technique
Common format for operative reports: 5: Findings and Technique: A: Tells how the patient was protected from feeling the pain of the operation. It gives t he type of anesthesia and how it was administered. The specific name of the anesthesia is usually included.Type of anesthesia
Common format for operative reports: 5: Findings and Technique: B: Describes how the patient was placed on the operating table:Surgical position
Common format for operative reports: 5: Findings and Technique: C: The surgical cut used to access parts of the body. It will describe the location, length, direction, and depth of the incision.Incision
Common format for operative reports: 5: Findings and Technique: D Describe what was done, how, and why it was done, and the patient's response. This is filled with names and sizes of instruments, suture materials and techniques, and conditions of the organs and tissues examined or removed.Description
Common format for operative reports: 5: Findings and Technique: E: Describe how the incision was closed, state that all surgical tools have been accounted for, and may include information about blood loss.Closure
Common format for operative reports: 5: Findings and Technique: E: Closure: 1 An important part of the Findings and Techniques section is the:sponge count
Common format for operative reports: 5: Findings and Technique: E: Closure: 2Every operative report must state that the surgeon can account for all surgical tools.
Common format for operative reports: 5: Findings and Technique: E: Closure: 3Prior to every procedure, a member of the surgical team counts item like sponges needles, and instruments. After the procedure, these items are counted again to ensure that nothing was left inside the patient.
Common format for operative reports: 6: Concerns the condition of the patient and is usually one or two sentences in length.Patient condition
Format for patient name:(Family/surname), (first name) normal lang, capitalize first lettter of the name and not caps lock PATIENT NAME: Ouddy, Busaba
Format for Date:November 15 --
Format for Name of Physician:(First name), (surname), (title/specialization) SURGEON: Henry D. Sousa, DPM ANESTHESIOLOGIST: Jeffrey B. Morgan, MD
Operative report dissection notes: 1:Do not start your sentence with a number particularly if it is anything measured. Always place an introductory phrase.
Operative report dissection notes: Preoperative and Postoperative Diagnosis:the preoperative and postoperative diagnosis should be the same or closely related. Both should be written in acceptable medical terms, without abbreviations or use of layman's terms. It is poor practice to simply write "SAME" for the postoperative diagnosis. PREOPERATIVE DIAGNOSIS: Halluz Limibus, right foot. POSTOPERATIVE DIAGNOSIS: Same (WRONG) must be: PREOPERATIVE DIAGNOSIS: Halluz limibus, right foot. POSTOPERATIVE DIAGNOSIS: Halluz limibus, right foot.
TITLE OF: OPERATION/PROCEDUREOPERATION PERFORMED: Cheilectomy, first metatarsophalangeal join, right foor.