MEDTRANS 2

• Operative report

  Detailed technical description of how a surgical procedure was done
• Surgical terminology

  • Terms related to anesthesia
  • Names of surgical positions
  • Instruments
  • Incisions
  • Suture techniques and materials
• Names for an operative report

  • Operative note
  • Surgical note
  • Surgical report
• Contents of an operative report

  • Preoperative diagnosis
  • Postoperative diagnosis
  • Name of operation or procedure
  • Indications for the procedure
  • Description of findings and techniques
  • Patient's name
  • Date of procedure
  • Surgeon's name
  • Case number
  • Patient room number
  • Names of assisting surgeons or physicians
• Preoperative diagnosis


  Explains why the operation or procedure is necessary, can be stated as a specific disease or a "rule out" or "suspected" diagnosis
• Postoperative diagnosis


  States the diagnosis after the operation or procedure is completed, a short descriptive title of what was actually found
• The preoperative and postoperative diagnosis should be the same or closely related, and written in acceptable medical terms without abbreviations or layman's terms</b>
• It is poor practice to simply write "SAME" for the postoperative diagnosis
• Preoperative diagnosis


  • Appendicitis
  • Severe abdominal pain
• Postoperative diagnosis


  • Appendicitis
• Operation/Procedure


  Describes the name of operation or procedure performed
• Operations/Procedures


  • Appendectomy - removed the appendix
  • Laparotomy with appendectomy - opened the abdomen and removed the appendix
• Indications


  Gives the reason for the operation or procedure
• Indications

  • 34-year-old woman with intermittent right upper quadrant pain, nausea, vomiting, fever, and chills, with multiple gallstones found on sonogram
  • 21-year-old man with 3-month history of thrombocytopenia and easy bruising, on high doses of steroids
• Findings and Technique


  The longest and most technical part of the operative report, describing the types of anesthesia, surgical position, incision, description of what was done, and closure
• An important part of the Findings and Techniques section is the sponge count, to ensure all surgical tools were accounted for
• Sponge, needle, and instrument counts

  • The sponge, needle, and instrument counts were correct
• Blood replacement

  • Due to excessive blood loss, the patient received 2 units of whole blood
• Patient Condition

  Concerns the condition of the patient after the procedure, usually 1-2 sentences
• Patient condition


  • The patient was sent to the recovery room in stable condition
  • The patient was sent to the recovery room in poor condition. Prognosis is poor.