The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standard IM.7.3.2 requires that you consistently place operative reports in the medical record according to your hospital policies and procedures and state laws. This requirement applies to outpatients as well as inpatients.
Most hospitals create policy and procedure by first referring to state law to determine if there are any specific requirements, and then referring to medical record and surgery text books for additional guidance. Classically, the record should include as applicable to the case:
Patient's name and unit number
Date of procedure
Name of surgeon and assistants
Pre-operative and post-operative diagnoses
Anesthetic agent used
Description of the findings, techniques, and procedure
Any laboratory or diagnostic procedure ordered
Condition of patient
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