Operative Notes in Chart Reviews

20 August 2012 / Chart Reviews / Comments Off on Operative Notes in Chart Reviews

The review of operative notes are of great value.

In the body of the operative note, the surgeon will describe the actual findings. This report will include the condition of the tissues, actual evidence of trauma detectives and bone, and may also include ranges of motion while under anesthesia.

Pay attention to the preoperative and postoperative diagnoses. Are they the same? If not, why?

Was anything new discovered as a result of the surgery? Do the findings coincide with the level of subjective complaints?

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