Timeframe for Operative Note Documentation

Published: 10/17/2023

Sources:
  • The Joint Commission
Relevant To:
  • Ambulatory Surgical Centers,
  • Critical Access Hospitals,
  • Hospitals

Reports of operative and other high-risk procedures should be written or dictated for inclusion in the medical record immediately after the operative or other high-risk procedure and before the patient is transferred to the next level of care.

The intention of an operative note is to ensure there is sufficient information about the procedure in the medical record immediately after surgery or other high-risk procedure so that the patient can be managed appropriately throughout the post procedu…

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