Operasjonsdokumentasjon

Operasjonsdokumentasjon refers to the comprehensive set of records and documentation generated before, during, and after a surgical procedure. This documentation is crucial for ensuring patient safety, facilitating communication among the healthcare team, and providing a legal record of the operation. It typically begins with pre-operative assessments, including patient history, physical examinations, and diagnostic test results, which inform the surgical plan.

During the operation, detailed notes are taken by the surgical team, including the surgeon, anesthesiologist, and nursing staff. These notes capture the specifics of the procedure, such as the type of surgery performed, any intra-operative findings, instruments used, medications administered, and any deviations from the planned course of action. Special attention is paid to the placement of implants or prosthetics, including serial numbers and locations.

Post-operative documentation is equally important. It includes a detailed operative report dictated or written by the surgeon, summarizing the entire procedure. This report is vital for follow-up care, future medical decisions, and medical-legal purposes. Anesthesia records, nurses' notes, pathology reports of specimens removed, and imaging studies are also integral parts of the complete operasjonsdokumentasjon. This collective information forms a critical part of the patient's medical record, ensuring continuity of care and accountability within the healthcare system.