In Malaysia, in most instances Health Information Management (HIM) /
Medical Records (MR) practitioners may only find the postoperative note documented in the medical record. The postoperative note is an operative or other high-risk procedure report documented by the surgeon after surgery in the postoperative phase. This after surgery phase is when the client leaves the Operating Room (OR) and is taken to a Post-Anaesthesia Care Unit (PACU) and continues until the patient is discharged from the care of the surgeon upon completion of the operative or other high-risk procedure and before the patient is transferred to the next level of care.

In addition to the postoperative note, a surgeon may also dictate an operative record in hospitals where dictation services are available, in Malaysia or in other countries.Some hospitals may create special forms to facilitate an operative record documentation.

Thus, it is common to find a comprehensive operative progress note documented by the surgeon written in the progress notes in the patient medical record. However, a HIM/MR practitioner may also find that the patient medical record often contains as well as a transcribed operative record. Both of this documentation is authenticated by the responsible surgeon.

HIM/MR practitioners must not be confused between postoperative evaluations documented by the surgeon with postanaesthesia evaluations documented by the anaesthesiologists.

The content for the postoperative progress notes and/or operative record will normally contain documentation as follows:

1. patient’s vital signs and level of consciousness
2. any medications, including intravenous fluids, administered blood, blood products, and blood components
3. any unanticipated events or complications (including estimated blood loss and blood transfusion reactions) and the management of those events, or the absence of complications during the procedure
4. name of the procedure and techniques associated with the performance of surgery
5. description of other procedures performed during operative episode
6. description of gross operative findings, including organs explored
7. postoperative diagnosis
8. name of operative surgeon and assistants
9. surgical specimens sent for examination
10. documentation of ligatures, sutures, number of packs, drains, and sponges used
11. date, time, and signature of responsible surgeon

If your hospital is seeking a hospital accreditation status for example the Joint Commission International (JCI) accreditation status or already JCI accredited or plans for a JCI re-survey, then it is only normal to comply with the JCI Standard ASC.7.2  which requires :

(i) that there is a surgical report or a brief operative note (which may be used in lieu of the written surgical report) available prior to the patient leaving the postanesthesia recovery area to support a continuum of postsurgical supportive care, thus meeting Measurable Element (ME) 2 compliance for this standard, and

(ii) that the surgical report or a brief operative note is documented with at least the minimum six (6) elements as required by JCI Standard ASC.7.2, ME 1 (which I have already included in the list above) for the written surgical report or brief operative note in the patient’s medical record.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA