Operative Report Example Template

An operational report is an important when performing a surgery. This is the official document that records what happens in the operating room.

How to prepare an operational report?

When you need to prepare one, make sure that it demonstrates the medical necessity to treat the patient, describe each part of the surgical procedure, and disclose the results of the surgery. Surgical reports are the documents most commonly used to reimburse claims made by surgeons, surgical teams, and institutions. Reviewers and payers use operational reports to verify that the documentation supports all codes provided in the claim. 

A surgical report is a report written in a patient's medical record to record the details of the surgery. Surgical reports are dictated directly after surgery and then transferred to the patient file. The information in the surgical report includes the preoperative and postoperative diagnosis and the condition of the patient after surgery. In the surgical file, medication before and after surgery, as well as patient information, medical history, (Hx, physical examination (PE).

A surgical report is generated after each surgery for recording and billing. While some surgeons create surgical notes using electronic templates or structured tools 1-3, most surgical notes are dictated, transcribed, or typed and represent the surgeon's memory of surgical details. In the surgical report, the "Procedure Description" section describes the details of what was observed and performed during the procedure. Below are some important points when preparing an operational report.

• Goal: Be sure to remember why the report needs to be done. The purpose of preparing the report is very important as this will help to decide what data needs to be gather and what source are to be used.

• Time Period: Know the time period that the report covers, if it is daily, weekly, monthly etc. This helps to prepare and collect data relating to a specific period. 

• Information: The type of data you will need for this report depends on the type of report you are preparing, an operational report will usually show the current activity in an organization. 
  • Preoperative Diagnosis;
  • Preoperative Diagnosis;
    
  • Procedure;
  • Physician;
  • Anesthesia;
  • EBL;
  • Complications;
  • Disposition.

• Success and Failures: Be sure to report on the weakness and effectiveness of a particular topic., state if expectations were meet or any shortcomings.

Download this Operational Report Template from our website. Make some changes in the document available in Microsoft word format to suit your needs.  If you like this template, please give us a big thumbs up. Your valuable feedback matters a lot to us. Head towards our website for some useful content.