Operative and High Risk Procedure Reports - Timeframe of Dictation or Written

In what timeframe must an operative or other high-risk procedure report be dictated and placed in the medical record?  

Any examples are for illustrative purposes only.

The report must be written or dictated immediately after an operative or other high risk procedure. An organization's policy, based on state law, would define the timeframe for dictation and placement in the medical record.

Most importantly, there needs to be sufficient information in the record immediately after surgery or other high risk procedure to manage the patient throughout the post procedure period. This information could be entered as the operative report or as a hand-written progress note. If the operative or procedural report is not placed in the medical record immediately following the procedure, then a progress note must be immediately entered after the procedure to provide pertinent information to the next provider of care.

'Immediately after surgery or procedure' is defined as "upon completion of procedure, before the patient is transferred to the next level of care". This is to ensure that pertinent information is available to the next caregiver. If the practitioner performing the operation or high-risk procedure accompanies the patient from the operating room to the next unit or area of care, the report can be written or dictated in the new unit or area of care. For the purposes of this requirement, The Joint Commission considers the Pre-Op, O.R. and PACU as the same level of care as the clinical team is essentially intact across these areas.

If the progress note option is used (see RC.02.01.03 EP 7), it must contain, at a minimum, comparable operative/procedural report information. The minimum required elements include; the name of the primary surgeon and assistants procedures performed and description of each procedure findings any estimated blood loss, any specimens removed, and the  post operative diagnosis.
Last updated on April 28, 2020
Manual: Ambulatory
Chapter: Record of Care Treatment and Services RC

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