et al in 201210 compared the computerized synoptic operative report
with dictated operative reports
Neither the operative report
nor the discharge summary made any reference to the mass adjacent to the lower pole of the left kidney as visualized on the ultrasound study.
We reviewed the medical records prior to data collection, with particular interest in the following variables: the fracture pattern (based on the Gartland classification) described in the operative report
and the displacement of the distal fracture fragment, the use of closed reduction via a cast or closed reduction percutaneous pinning, complications, and neurovascular status.
This prompted review of the operative report
, which read, "a limited left lateral thoracotomy was performed and the hemithorax entered through the third interspace." The posterior-lateral rib fractures were ultimately attributed to this surgical intervention from PDA repair.
This study is conducted to study the quality of operative report
for laparoscopic cholecystectomy and find ways to improve these records.
The patient's electronic medical record was reviewed for details on patient demographics, clinical history, operative report
and pathology results.
Per operative report
, there was traumatic compression injury with blowout perforation of the right ventricular apex.
Taylor, "Resident training and the dictated operative report
: a national perspective," Canadian Journal of Surgery, vol.
For example, if the auditor is looking at a surgical procedure issue, he or she needs the operative report
but should not be looking at the E&M notes that do not pertain to the surgery.
Brodman's operative report
, which was dictated before complications arose and was never supplemented.
One seldom finds an operative report
of procedures performed on such patients.
Hoffman then dictated his 2-page operative report
and went across the street from the hospital to eat lunch with Dr.