Operation report

An operation report ( abbreviation : operation report ) is part of the patient file with written information about the type, the course, the achieved goal and any problems with an operative measure carried out . The operation report is very important to surgeons and related professions as a document with great clarity. It is used both to describe the disease by type and stage and thus directly to the patient, and sometimes to the surgeon in the event of a legal dispute through its precise description of the process. The surgery report is important for further interventions (reoperations) that are necessary immediately or much later, as it informs the surgeon about the expected conditions.

Information

The surgery report often contains the following information:

• Patient identification (surname, first name, date of birth, possibly identification number)
• Date of operation, time of start and end / duration of the operation
• Operating theater, theater
• selected anesthetic (type of local anesthesia or general anesthesia )
• Involved persons:
  • Surgeon , assistant, instrument operator , OR jumper
  • Provided that no independent anesthesia record is made, of course, the anesthesiologist / -in, anesthetist nurse / nurses
• Name of the diagnosis , possibly diagnosis code
• Name of the operation, possibly therapy key
• The indication for the procedure
• For emergency operations: Circumstances that limited preoperative diagnosis and preparation
• A list of preoperative risks:
  • general operational risks (aggravating secondary diagnoses)
  • local risks (again, risks for the specific intervention based on the patient's condition, such as previous operations)
• Reference to written consent after clarification in the case of critical consideration, but also in the case of oral emergency clarification (witnesses)
• Position the patient
• A detailed (step-by-step), comprehensible description of the operative procedure
• ( Intraoperative ) findings obtained during the operation :
  • Description of the surgical situs (particularly visible and palpable pathological findings that can assess the stage)
  • If necessary: histological frozen section diagnosis , radiographic findings (particularly in the traumatology ), ultrasound findings , rare: control laboratory findings
• Any operative complications
• Any incidents of anesthesia if they interfered with the surgical procedure or if no separate anesthesia protocol is drawn up
• All possible incidents of local anesthesia performed by the surgeon (if the anesthetist is responsible for anesthesia, the aforementioned applies)
• Introduced foreign material ( prosthesis , stent , implants , etc.) giving the exact model and possibly charge (because of product liability law)
• Type of surgical closure and suture or staple material used
• Signature of the surgeon or other authentic signature

literature

• Holger Siekmann, Lars Irlenbusch: Operations reports , trauma surgery , Springer-Verlag, 2012
• Florian Leiner: Medical Documentation: Basics of Quality Assured Integrated Health Care , Schattauer Verlag , 2012
• Monika Hagen: Operation reports for beginners: Preparing the operation - dictating the report , Georg Thieme Verlag , 2005
• Rudolf Ratzel, Bernd Luxenburger: Handbuch Medizinrecht , Deutscher Anwaltverlag, 2008 (p. 758)
• D. Kohn, Tim Pohlemann: Surgical Atlas for orthopedic trauma surgery advanced training , Springer-Verlag, 2014
• Jürgen Bauch, Hans-Peter Bruch, Jörg Heberer, Joachim Jähne: Treatment errors and liability in visceral surgery , Springer-Verlag, 2011

Web links

• Operation report , in the Roche Lexicon Medicine , 5th edition