what should i ask when getting report on my surgical patient

Ask your primary healthcare provider, your local medical society, or health insurance company for information about the healthcare provider or surgeon's experience with the procedure. Ask about the healthcare provider or surgeon's credentials and whether he or she has any additional certifications or experience in doing the procedure.

Full Answer

What questions should I review with my healthcare provider before surgery?

The following are important questions to review with your healthcare provider before surgery. Ask your healthcare provider to explain the answers clearly and ask for further explanation if you are having trouble understanding an explanation and/or any medical terms. Some people find it helpful to write their questions down ahead of time.

Can I get a copy of my surgical report?

You have the rights to all of your medical information from any physician you have seen. This includes your operative reports. Answer: A release of records request is normal procedure. You certainly are allowed to have copies of all your medical records.

What should be included in a postoperative report?

“It lists your name, the date of the procedure, the preoperative diagnosis, the post operative diagnosis,” he said. “We give a brief clinical history, the type of anesthesia we used, and the technical details of the surgery.” The document also describes complications, blood loss, and whether specimen were taken.

What should be included in an operative summary for surgery?

“We give a brief clinical history, the type of anesthesia we used, and the technical details of the surgery.” The document also describes complications, blood loss, and whether specimen were taken. My operative summary included the size of the hernia, 6×4 centimeters, its location, and what type of mesh was used to fix it.

What should I ask my post op patient?

Questions to Ask your Doctor AFTER SurgeryWhat possible side effects should I look for after treatment?What are the signs of infection?What do I do about constipation?What kind of timeframe am I looking at for recovery?Is it possible to completely recover from treatment of a Brain aneurysm/AVM/Stroke?More items...•

What questions should you ask about surgery?

10 Questions to AskWhy do I need this operation?How will the operation be performed?Are there other treatment options, and is this operation the best option for me?What are the risks, benefits, and possible complications for this operation? ... What are my anesthesia options? ... What can I expect before the operation?More items...

What questions should a nurse ask a patient?

Here are 5 questions every medical practice should ask when a new patient arrives.What Are Your Medical and Surgical Histories? ... What Prescription and Non-Prescription Medications Do You Take? ... What Allergies Do You Have? ... What Is Your Smoking, Alcohol, and Illicit Drug Use History? ... Have You Served in the Armed Forces?

Do surgeons write reports after surgery?

An Operative report is a report written in a patient's medical record to document the details of a surgery. The operative report is dictated right after a surgical procedure and later transcribed into the patient's record.

What are the questions doctors ask?

Terms in this set (12)What brings you in today? Why are you here?What hurts? The part of your body.What are your symptoms? Describe the problem.How long has this been going on? ... Has the pain been getting better or worse? ... Do you smoke? ... Do you have a family history of this? ... Do you take any medicines or supplements?More items...

How do you ask someone after surgery?

General Get Well Message After SurgeryHope you feel all the love surrounding you right now.Thinking about you today and hoping it's a good one for you.Get better and get back to your amazing self soon!Sending you a warm hug, love, and prayers.Sending good, healthy recovery vibes your way.

What are 6 Sample questions for a practice patient survey?

We will present the patient survey questions and explain why these examples are important.How did you find the experience of booking appointments? ... Were our staff empathetic to your needs? ... How long did you have to wait until the doctor attends to you? ... Were you satisfied with the doctor you were allocated with?More items...•

What should a nursing report include?

What to cover in your nurse-to-nurse handoff reportThe patient's name and age.The patient's code status.Any isolation precautions.The patient's admitting diagnosis, including the most relevant parts of their history and other diagnoses.Important or abnormal findings for all body systems:More items...•

What are the 7 components of a patient interview?

The RESPECT model, which is widely used to promote physicians' awareness of their own cultural biases and to develop physicians' rapport with patients from different cultural backgrounds, includes seven core elements: 1) rapport, 2) empathy, 3) support, 4) partnership, 5) explanations, 6) cultural competence, and 7) ...

What are the main parts of an operative report?

These elements include:the name of the primary surgeon and assistants,procedures performed and a description of each procedure,findings,estimated blood loss,specimens removed, and.a post operative diagnosis.

What does the operative report consist of?

Operative reports should be dictated or written in the medical record immediately after surgery and should contain a description of the findings, the technical procedures used, the specimens removed, the postoperative diagnosis and the name of the primary surgeon and any assistants.

What is the purpose of operative report?

An operative report documents the details of surgery. The Joint Commission on Accreditation of Healthcare Organizations directs that it be dictated immediately after surgery so there is sufficient information in the medical record prior to the patient's transfer to the next level of care.

What should a healthcare provider explain about a surgical procedure?

Your healthcare provider should clearly explain the surgical procedure, such as the steps involved and provide you with examples. You should ask if there are different methods for doing this operation and why he or she favors one way over another.

How to minimize the risks of surgery?

You can minimize the risks of surgery by choosing a healthcare provider who is thoroughly trained and experienced in doing the procedure. You may ask the healthcare provider about his or her experience with the procedure being done, including the number of times he or she has done it, and his or her record of successes, as well as complications.

Why is it important to ask for a second opinion?

A second opinion can help you make an informed decision about the best treatment for your condition and can help you weigh the risks and benefits against possible alternatives to the surgery.

Why is it important to learn about your surgeon?

Learning About Your Surgeon. It is important to have confidence in the healthcare provider who will be doing your surgery. Whether this is someone you have chosen yourself, or a healthcare provider or surgeon you have been referred to, you can make sure that he or she is qualified.

Why do people have surgery?

Reasons to have surgery may vary from relieving or preventing pain to diagnosing a problem to improving body function. Ask your healthcare provider to specifically explain why this procedure is being recommended for you and make sure you understand how this may improve your medical condition.

Who should give anesthesia for surgery?

You should also ask who will be giving the anesthesia (such as an anesthesiologist or a nurse anesthetist ; both of whom are highly qualified to give anesthesia) and ask to meet with that person before your operation.

Where to discuss surgery costs?

Before you have surgery, discuss the costs with someone from the finance department at your healthcare provider's office . These costs may include the following:

Why is it important to get a nursing report?

Getting a good nursing report before you start your shift is vitally important. It is not only important for the nurse but for the patient as well. Nursing report is given at the end of the nurses shift to another nurse that will be taking over care for that particular patient. Nursing report is usually given in a location where other people can ...

Why do nurses give reports outside of the room?

If you are required to give report outside of a patient’s room try to keep your voice down so other patients and family members can not hear. Most nurses use the SBAR tool as a guide to help them give report, which is highly recommended.

Why is it important to disclose allergies prior to surgery?

1  All allergies, including food, medications, and those that cause skin irritation, should be included. By placing this information on your hospital chart, it will make the various departments of the hospital, including pharmacy and nutritional services, aware of the allergies.

What are the religious issues in surgery?

Religious Issues. Some religions forbid blood transfusions and other medical procedures. If this is the case, the surgeon must be aware of the conditions under which they are operating prior to surgery. Some surgeries would not be able to take place if the religious objection would impact the level of care.

What does it mean when a patient has a fever before surgery?

If a patient begins to feel ill or has a fever in the days preceding surgery, the surgeon needs to be made aware. The surgeon may decide it is safe to continue with surgery or may opt to postpone the procedure. A fever is a sign of possible infection and should be disclosed, to prevent wasted time and energy for both the patient and the surgeon.

What supplements should a surgeon know about?

Your surgeon needs to know about all of the medications you are taking, including prescription, non-prescription drugs, herbal supplements, and vitamins. 1  Supplements are often overlooked when listing current medications, but it is very important that the surgeon is aware of any supplements as they can interact with anesthesia and may increase bleeding.

Should a patient be disclosed to the surgeon?

For example, a patient who is having knee replacement surgery needs to make their surgeon aware of the fact that they are diabetic and using insulin. 1  Without this information, the hospital is unable to provide care for all of the conditions, which could harm the patient.

Can a surgeon prescribe alcohol?

2  Patients who are dependent upon alcohol can have issues ranging from tremors to seizures as they begin to experience withdrawal. If the surgeon is aware that the patient is chemically dependent upon alcohol they can prescribe medications ...

Can surgery leave scars?

Previous Illnesses and Surgeries. Surgeries leave scars, both internal and external, and can change surgeries that follow. A surgeon should be well aware of any previous surgeries, especially those that take place in the same region of the body.

How to correct errors in patient record?

If there are errors in your patient record, you can write a letter to the healthcare administrator outlining those errors and the needed corrections. Mention your name, date, social security number, and other vital information, then staple a copy of the page that contains an error. The provider must respond and act on your request within 60 days.

What to include in a medical delivery request?

Make sure to include: Your name, including your maiden name (if applicable) Social Security number. Date of birth. Address and phone number. Date (s) of service (months and years under the doctor’s care) List of records you need. The delivery format you need.

What is the right to access medical records?

Under the Health Insurance Portability and Accountability Act (HIPAA), you or your designated patient advocate has the right to obtain copies of your medical records. Patients have the right to access medical records, get copies, and make corrections. Keeping medical record copies of your health care records can help patients stay on top of their health.

How to get medical records?

To request the medical records, you need to visit your healthcare provider’s office or speak to the administrative staff in charge. Some hospitals offer online medical records through their website.

How long does it take to get a copy of medical records?

Healthcare providers have 30 days to gather and provide copies of your medical records, so make sure you’ve allowed enough time. If you feel your rights to access your health information in a timely fashion have been violated and may merit legal action, you can file a complaint with the U.S. Department of Health & Human Services; just make sure to file the complaint within 180 days. The COVID-19 pandemic has made wait times longer, expect additional business days.

How long does a physician have to provide a copy of a medical record?

Under HIPAA, a physician has 30 days to provide the patient or the patient’s legal representative with a copy of the requested medical records; however, if the medical records are not maintained or are not accessible on-site, then a physician has 60 days to provide the records.

What to do if you need someone else's medical records?

If you need another person’s medical records, you need to bring some additional legal documents to show your rights to access someone else’s documents. Ask about these formalities in advance. Most of the time, you need to fill the form for requesting your records. If there is no such form, you can make a written request.

What records do patients want to request?

Some records that patients may want to request are test results, reports for surgeries, doctor’s notes, discharge summaries and specialists’ reports.

Who can request records from a patient?

According to HIPAA, patients have the right to request their records. Other individuals can also request records on behalf of a patient. These include a parent, legal guardian, patient advocate or caregiver with written permission from the patient.

Why do people request medical records in person?

Requesting medical records in person allows a patient to make sure they get the exact records they want, Ennis added.

How to request medical records of a deceased patient?

Requesting medical records of a deceased patient requires someone to be an executor of the deceased patient’s estate or to get permission from the executor. If no executor exists, someone can petition to become the executor through probate court. The petitioner must have documentation of their relationship to the deceased.

What is ER records?

Psychotherapy notes and other mental health notes that may lead to patient harm. ER records that are specific to hospital or company procedure and not patient care. Information involved in a lawsuit. Records that include information about other people or a third party that may be harmed by the release of information.

How long does it take to get a health record?

Providers have anywhere from 30 to 60 days to process a request. But many facilities may provide records within five to 10 days, according to American Health Information Management Association.

How much does it cost to get a medical record?

The cost for medical records ranges from $0.25 to $2.00 per page in most states. Check your state’s fees on the Records Company website.

Do you have to sign a release to get your own information?

The patient has the right to his or her own chart. You should not have to sign a release to get your own information. I will speak to the office manager instead of the receptionist concerning this matter.

Can a surgeon keep medical records?

You certainly are allowed to have copies of all your medical records. In addition, your surgeon is not "hiding" anything, but rather going through the normal procedure to fulfill your request. In order to release records to you, physicians have an obligation to make sure that your records are actually released to you and not to anyone else. This may mean going to the office to sign paperwork.

Do you have rights to all medical records?

You have the rights to all of your medical information from any physician you have seen. This includes your operative reports.

Can you request a release of medical records?

Answer: A release of records request is normal procedure. You certainly are allowed to have copies of all your medical records. In addition, your surgeon is not "hiding" anything, but rather going through the normal procedure to fulfill your request.

Can medical records be released to someone else?

It may seem like you were given the run around but there are specific laws and regulations that require one to have a written request and proof of identity before any medical records can be released. The records can only be released to the person requesting them unless there is an additional release that says it can be given to someone else. Good luck.

Who is responsible for surgery outcomes?

Surgery outcomes are typically communicated to family members – who may not be that great about relaying that information, or they share it with patients while they are still feeling the effects of their anesthesia.

What is an operative summary?

Turns out there is such a thing, it’s called an operative summary. “It’s a dictated note that describes the technical components of the surgery,” Morris explained to me.

Who said "count backwards" in the operating room?

Zakiya Gibbons, a recent college graduate recalls counting backwards in the operating room. “I remember just cutting out mid-sentence in my own head, I was like ‘ten, nine, eigh…’ and then that was it.”

Who said "one moment I'm joking with the nurses, the next thing I know, I was in?

Fritz Graham of Philadelphia found this part of the experience somewhat disorienting. “One moment I’m joking with the nurses, the next thing I know, I was in the OR with a cast on my hand,” he said.