Operation Report

[foreveryoung]

Can anyone tell me if there is and operation report required to be filled out after surgery? Something like, made incision 2 inches below this area, or found this abnormality etc. I was told by a VA surgeon I should have had one.

Thanks

[Berta]

Yes- there should always be a surgical narrative done.

I think sometimes it is transcribed from a tape.

[Pete53]

Ask for copies of your progress notes usually on computer.

[EODMOMMY]

Yes- there should always be a surgical narrative done.

I think sometimes it is transcribed from a tape.

If you are referring to a surgery operation type report, yes an operative report is always done. They are suppose to be done right after the surgery (according to my medical transcription class), but depending on how many cases the surgeon may have, they may do them later in the day with the notes from the surgery. But they should be done within 24 hours.

If this was some procedure done in a regular doctors office (i.e. mole removal, other in office procedures), it all depends on the doctor. It would be documented in the patients records, but not necessarily as an operative report, unless you went to a specialist.

You can go to the doctor or hospital who performed the procedure and request a copy of your records. According to the new HIPPA laws you are allowed to inspect your records and most doctors do not have a problem giving you copy of a report to give to another doctor.

[foreveryoung]

Thanks for the replies.

I should have stated this earlier, this operation was performed in Frankfurt General Hospital Germany in 1976. I have a copy of SMR but there are no reports, just a lab test of organ removed.

This operation was performed by a military surgeon with the rank of Major.

Is this something the VA should have reviewed and have had? Can this be grounds for CUE, for not providing or maintaining these reports? How can the VA make a well grounded denial if reports are missing?

[foreveryoung]

Were these reports also required for military hospitals in 1976?

Edited June 19, 2006 by foreveryoung

[Guest jstacy]

Operative reports are the property of the hospital and not the MD who performed it. The reports will be part of the hospital record and that is where you can find it.