How to Write a Postoperative Report

Postoperative reports provide a step-by-step account of exactly what occurred during a surgical procedure. The report includes every detail from the reason for the procedure to how well the patient handled the procedure. Patients have the right to obtain a copy of the report. The reports are used for insurance reasons, hospital records and personal reasons. A surgeon present during the operation must dictate the report and send it off to be transcribed.

Instructions

• 1

  Identify the patient. The first line of the report should identify the patient. Patients are identified by name, date of birth and medical record number.

• 2

  Identify the surgery date and physician involved in the procedure. The date of admission and surgery should be indicated along with the discharge date -- if known. The surgeons should also be listed. Include the attending surgeon as well as residents and medical students who were present.

• 3

  Indicate the preoperative diagnosis. The diagnosis is the reason why the surgery is being performed.

• 4

  Provide the name of the procedure. Describe the procedure in a few words.

• 5

  Take note of the type of anesthesia used. Indicate the use of any hemostasis -- means of preventing blood flow -- as well.

• 6

  Describe intraoperative findings and indicate the reasons why the surgery was performed.

• 7

  List the steps of the procedure. Describe, in detail, exactly what happened during the procedure. Begin with marking of the surgical site and end with suturing.

• 8

  Document patient aftercare. Indicate how the patient handled the surgery and postoperative instructions given to the patient and caretakers.

• 9

  Dictate the report.

• 10

  Sign the operative report. The operative report should be read over and signed by the attending surgeon.