Forum - Questions & Answers

Jul 13th, 2011 - Spalmer

Documentation requirements for Operative reports

I have been unable to locate any set of guidelines for OP report documentation. I know the JCAHO has published them at some point, I am, however unable to find them. Any help would be appreciated!

Jul 22nd, 2011 -

re: Documentation requirements for Operative reports

Here is the JCAHO Standard with cited manual sections:
JCAHO Standard IM.6.30
Element of Performance (EP 3) details data elements for the dictated operative
report
IM.6.30 EP3 Operative reports (dictated) immediately after a procedure must
record the:
IM.6.30 EP3 Name of primary surgeon & assistants
IM.6.30 EP3 Findings
IM.6.30 EP3 Procedure(s) performed
IM.6.30 EP3 Description of procedure
IM.6.30 EP3 Estimated blood loss, as indicated
IM.6.30 EP3 Specimens removed
IM.6.30 EP3 Post-operative diagnosis



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