Tag: Operative note

The operative note is a cornerstone of a patient's medical record, detailing the surgical procedure performed. Accurate documentation is crucial for continuity of care, billing, and legal protection, making the question of **who is responsible for the operative note** a critical one in the healthcare field.

Over 300 million major surgical procedures are performed worldwide each year, and each one requires meticulous documentation. A dictated operative report is the crucial, comprehensive record created by a surgeon detailing every aspect of a surgical procedure for the patient’s permanent file.