Friday, September 7, 2007

Ingredients For Surgical Reports

Reports describing any type of invasive surgery, cosmetic surgery, or an outpatient procedure (such as a colonoscopy or barium swallow), might include the following intelligent building blocks:

  • Patient Demographics

  • Copies

  • Preoperative Diagnoses

  • Postoperative Diagnoses

  • Surgical Team

  • Anesthesia

  • Name of Procedure

  • Preoperative Findings/Indications for Procedure

  • Description of Procedure

Next: Ingredients for "SOAP" Notes

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