- Joined
- Nov 30, 2005
- Messages
- 83
- Reaction score
- 2
What exactly needs to be included in an op note? What doesn't need to be included?
Obviously, a good account of the operation performed. I'm not talking about that. I'm talking about the other stuff. And I'm asking with respect to Hand Surgery.
Of the following, what is and isn't necessary?
Tourniquet time - it's recorded elsewhere usually.
Fluids, blood loss. - it's hand surgery this is usually minimal.
Where to begin? Patient seen in preop, marked, consent checked etc?
Placing tourniquet, prepping, draping etc. - is that given or do you really have to say it?
Time out? Details of time out?
It may seem trivial but when you add up thousands of op notes, it's a decent bit of time spent.
How much can be left out of the op note fluff, without compromising the (legal) integrity of an op note?
Obviously, a good account of the operation performed. I'm not talking about that. I'm talking about the other stuff. And I'm asking with respect to Hand Surgery.
Of the following, what is and isn't necessary?
Tourniquet time - it's recorded elsewhere usually.
Fluids, blood loss. - it's hand surgery this is usually minimal.
Where to begin? Patient seen in preop, marked, consent checked etc?
Placing tourniquet, prepping, draping etc. - is that given or do you really have to say it?
Time out? Details of time out?
It may seem trivial but when you add up thousands of op notes, it's a decent bit of time spent.
How much can be left out of the op note fluff, without compromising the (legal) integrity of an op note?
