The following Q&A is based on JCAHO requirements in regards to documentation of operative reports.
Q: In what timeframe must an operative report be dictated and placed in the medical record?
A: The operative report must be written or dictated immediately after an operative or other high risk procedure. An organization's policy, based on state law, would define the timeframe for dictation and placement in the medical record. The most important issue is that there needs to be enough information in the record immediately after surgery in order to manage the patient throughout the postoperative period. This information could be entered as the operative report or as a hand-written operative progress note.
If the operative report is not placed in the medical record immediately after surgery due to transcription or filing delay, then an operative progress note should be entered in the medical record immediately after surgery to provide pertinent information for anyone required to attend to the patient. This operative progress note should contain at minimum comparable operative report information. These elements include:
- the name of the primary surgeon and assistants,
- procedures performed and a description of each procedure,
- findings,
- estimated blood loss,
- specimens removed, and
- a post operative diagnosis.
Immediately after surgery is defined as "upon completion of surgery, before the patient is transferred to the next level of care". This is to ensure that pertinent information is available to the next caregiver. In addition, if the surgeon accompanies the patient from the operating room to the next unit or area of care, the operative note or progress note can be written in that unit or area of care.
Medical record documentation is required before billing for services. The guidelines above will help us meet billing requirements as well.