Operative Note

If the operative note is not on the chart after 2 days what is your thought of querying for the operative note?


  • We do not.  That is a HIM function in our organization. 
  • I agree with Erica. However, if you can approach the surgeon directly, he or she may appreciate the reminder. Sometime dictations get overlooked or get lost in the transcription process and the surgeon would rather take care of it early instead of days after discharge. 
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