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The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
The World Health Organization (WHO) published the WHO Surgical Safety Checklist in 2008 in order to increase the safety of patients undergoing surgery. [1] The checklist serves to remind the surgical team of important items to be performed before and after the surgical procedure in order to reduce adverse events such as surgical site infections or retained instruments. [1]
Surgical history The surgical history is a chronicle of surgery performed for the patient. It may have dates of operations, operative reports, and/or the detailed narrative of what the surgeon did. Obstetric history The obstetric history lists prior pregnancies and their outcomes. It also includes any complications of these pregnancies.
In 1991 the National VA Surgical Risk Study (NVASRS) began in 44 Veteran's Administration Medical Centers. By 31 December 1993, there was information for 500,000 non-cardiac surgical procedures. In 1994 NVASRS was expanded to all 128 HVA hospitals that performed the surgery.
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Surgical positioning is the practice of placing a patient in a particular physical position during surgery. The goal in selecting and adjusting a particular surgical position is to maintain the patient's safety while allowing access to the surgical site. Often a patient must be placed in an unnatural position to gain access to the surgical site ...
Hoppes, 54, went to Mission Hospital Feb. 24 for a spine surgery to remove a damaged, arthritic or herniated disc in her upper spine, according to court documents and her estate’s lawyer.