How to Write a Lab Report on a Surgery

After a surgical procedure, a surgeon will record his notes through a digital voice recorder and explain exactly why he did the procedure, how he did it and the equipment that was used to complete the surgery. Once the notes are recorded, he will provide them to a medical transcriber who will type the recordings into word format to be provided to the patient or placed in the patients file. A lab report also allows the surgeon to document exactly what he saw and treated during the procedure, so that he may relay the exact information to the patient.

Instructions

• 1

  State the preoperative diagnosis. This indicates the reason or cause for the surgery.

• 2

  State the postoperative diagnosis, which will confirm the reason for the surgery and allow the surgeon to list any other possible causes that may have been causing the patient pain.

• 3

  List the exact name of the operation that was performed.

• 4

  Provide the surgeon's name, directly under the performed operation.

• 5

  List any anesthesia given for the surgery, such as local or general anesthesia.

• 6

  Provide the estimated amount of blood loss the patient experienced during surgery.

• 7

  Describe any intraoperative findings the surgeon experienced during the surgery. This may include what the surgeon saw during the surgery that was expected and related to the surgery reason, or it may also include other findings that were not related, such as an inflamed organ.

• 8

  Describe the surgery in detail, based on the surgeon transcriptions. During or after the surgery, the surgeon will transcribe what happened during the procedure, including preparation, incisions, the actual procedure and any complications, making sure all instruments counts were correct after the procedure, and when the incision was closed. The surgeon may also add into the report the patient's pain levels, as in howmeaning how the patient deals with pain after the procedure, and their condition based on vital signs and whether the vital signs are stable or fluctuating.