Operative Note Documentation Basics
- By John Verhovshek
- In Coding
- December 22, 2015
- Comments Off on Operative Note Documentation Basics

A surgeon’s operative note should provide all the necessary documentation to describe the procedure performed. The note should “stand alone” as the only document needed to understand why the surgery was undertaken, and what occurred.
The following documentation that should be on every operative note:
- Patient’s name
- Date
- Preoperative Diagnosis
- Postoperative Diagnosis
- Surgeon’s Name
- Assistant Surgeon/Co‐Surgeon
- Procedure
- Indications for Surgery
- Findings at Surgery
Include Post-Op Diagnosis in Operative Note
Whenever possible, try to differentiate the pre-operative and post-operative diagnoses. For instance, a pathology report can provide additional details that allow for a more precise post-operative diagnosis. You may also wish to report any underlying co-morbid conditions that can affect the surgical outcome
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Where did you get the above information? I would like to reference it.