Surgical Documentation Guidelines

The medical record is a major tool for communicating patient information and is therefore an integral component of patient safety. One part of the medical record that has defined content and completion time frames in The Medical Center of Aurora/ Centennial Medical Plaza's Medical Staff Rules & Regulations is the "Operative, Special Procedure and Tissue Reports." The following are the requirements for documentation after a procedure is done.

Written Operative Progress Note

Contents must include:

• Date of Surgery
• Name of surgeon and assistant
• Findings
• Procedures performed
• Estimated blood loss, specimens removed
• Post-op diagnosis
• Fluids
• Anesthesia
• Pre-op Diagnosis
• Name and Patient Hospital ID#
• Time of surgery
• Prosthetic devices or implants used, if any
• Complications, if any

There is a form on the Intranet under Hospital Forms titled Brief Post Operative Procedural Note that includes all of the above content. If this form is not used, the content above must be documented in Physician Progress Notes.

A written operative progress note (as defined above) will be present on the chart upon transfer to the next level of care, e.g.:

• Cath Lab to Cath Recovery
• OR to PACU
• GI Lab to Day Surgery Recovery
• Operating Room to ICU

Dictated Operative Report

Contents must include:

• Date of surgery
• Name of surgeon and assistant and/or other practitioners performing significant tasks
• Pre-operative and post-operative diagnoses
• Name of specific surgical procedure(s) performed
• Type of anesthesia administered
• Estimate blood loss
• Complications, if any
• A detailed, narrative description of techniques, findings, and the tissues removed or altered and their disposition
• Prosthetic devices or implants used, if any
• Patient name and hospital ID #
• Time of surgery
• Description of the specific tasks conducted by practitioners other than the primary surgeon

A comprehensive operative report (as defined above) will be dictated within 24 hours of completion of the procedure.

A dictated operative report is required for all assisted deliveries.