Surgical Documentation, Informed Consent, and Operative Note

Surgical Documentation, Informed Consent, and Operative Note
Book Chapter
Andreas M. Kaiser
Chassin’s Operative Strategy in General Surgery, 29 May 2022; pp 89–91 [Springer]
Abstract
This chapter defines the value and describes the elements of good surgical documentation, and gives the fundamentals of writing a good operative note. Solid documentation is our friend as well as our “protective insurance,” while poor, incomplete, or altered documentation can easily turn into our worst enemy. But the value of documentation is not just defined by its role in litigation cases but by its importance for continuity of care, cost-saving measures, reimbursement, as well as quality control and research efforts.