Hospital Acceptable Operative Report
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ACCEPTABLE OPERATIVE REPORT 1 This operative report follows the standards set by the for sufficient information to: • identify the patient • support the diagnosis • justify the treatment • document the postoperative course and results • promote continuity of care This operative report also provides: • name of facility where procedure was performed • date of procedure • patient history • CPT code Blair General Hospital Patient Name: Preoperative Diagnosis: Bilateral upper eyelid dermatochalasis Postoperative Diagnosis: Same Procedure: Bilateral upper lid blepharoplasty. ACCEPTABLE OPERATIVE REPORT 2 This operative report follows the standards set by the JCAHO and AAAHC for sufficient information to: • identify the patient • support the diagnosis • justify the treatment • document the postoperative course and results • promote continuity of care This operative report also provides: • name of facility where procedure was performed • date of procedure • patient history • CPT code Patient Name Location of surgery: Riverview Surgical Preoperative Diagnosis: Facial and neck skin ptosis Cheek, neck, and jowl lipotosis Facial rhytids Postoperative Diagnosis: Same Procedure: Temporal cheek-neck facelift Submental suction assisted lipectomy Surgeon: ACCEPTABLE OPERATIVE REPORT 3 This operative report follows the standards set by the for sufficient information to: • identify the patient • support the diagnosis • justify the treatment • document the postoperative course and results • promote continuity of care This operative report also provides: • name of facility where procedure was performed • date of procedure
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