An operative report states the preoperative and postoperative diagnoses, the procedure performed, the surgeon and assistants, anesthesia, findings on entry, the technique used, specimens taken, and estimated blood loss.
It is dictated by the surgeon following the procedure.
Alternative Names:
Surgical Report, Operation Note
Why it Matters?
The findings section is where causation evidence sits, because it records what the surgeon actually observed rather than what imaging predicted. A report describing chronic degenerative changes and no acute pathology contradicts a claim that the surgery addressed traumatic injury. The comparison between preoperative and postoperative diagnoses also reveals whether the anticipated pathology was confirmed.
Frequently Confused with
Related terms
Frequently asked questions
Why is the findings section important?
What does a diagnosis discrepancy indicate?
