Surgical Procedure Documentation
Any surgical procedure requires special documentation. Preoperative notes are made by the anesthesiologist and surgeon prior to the procedure, and nurses report preoperative patient preparations. The entire procedure itself is then recorded, along with an anesthesia record, an operative report, and a post-anesthesia or recovery room report. When tissue is removed for evaluation, a pathology report also must be present.
The anesthesia report notes any preoperative medication and the response to it, the dosage of the anesthesia administered and the route of administration, the duration of administration, the patient’s vital signs while under anesthesia, and any blood products administered to the patient during the procedure, and other preoperative information. The anesthesiologist or nurse anesthetist is responsible for this documentation.
The operative report describes in detail the surgical procedures performed on the patient. The content of the operative report is found in table 4.4.
The operative report should be written or dictated by the surgeon immediately after surgery and become part of the health record as soon as possible. When there is a delay in dictation or transcription, a progress note describing the surgery should be entered into the patient’s health record. Reports of non-surgical other procedures or treatments will require documentation as well. These may include administration of blood transfusions, chemotherapy documentation, and more.
Immediately after the procedure, the patient is evaluated for a period of time in a special unit called a recovery room. Monitoring is important to ensure the patient sufficiently recovers from the anesthesia and is stable enough to be moved to another location. The recovery room report includes the post-anesthesia note (if not found elsewhere), nurses’ notes regarding the patient’s condition and surgical site, vital signs, intravenous fluids, and other medical monitoring.
A pathology report is dictated by a pathologist after examination of tissue received for evaluation. This report usually includes descriptions of the tissue from a gross or macroscopic (with the eye) level and representative cells at the microscopic level along with interpretive findings. Sometimes an initial tissue evaluation occurs while the surgery is in progress to give the surgeon information important to the remainder of the operation. A full written pathology report would follow.
