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O.R. reports...

LoLLo Posts: 694
edited 06/11/2012 - 8:25 AM in Back Surgery and Neck Surgery
It kind of scared me to hear about these people whose doctor's have left instruments inside of them, messed with the wrong discs, screwed something else up, etc... SO, I got my O.R. reports for both of my surgeries this year and read them.

They are REALLY detailed. Pages and pages long, some by my Neurosurgeon, some by my Vascular surgeon... They even cover the assistants and who did what test to make sure nothing was left inside, what x-rays were done to be sure of placement, what what used (I guess they used certain screws to mark areas?) to mark the correct areas for alignment, what instruments were used, what gauge, why, how everything turned out... How many mm's each piece of disc removed was, what color, texture, how many mLs of blood loss, how many mLs of specific fluids, etc, etc.... ANYTHING and EVERYTHING. They covered more bases than I knew existed. I didn't even know they removed scar tissue from along the L5 nerve site, or cut any of my ligaments in the back through the front by looking at the right side through the left.... All this interesting stuff.

Do all doctors write reports like this, or do some skimp or skip out on it... And is that why mistakes seem to happen and aren't caught right away???? I didn't even think to get an O.R. report, because I consider my surgery a great success... But it's a very interesting read... And they took more precautions than I had ever imagined... All the marking, xraying before and after, during, having assistants test, etc...

Just wondering how those work. Are O.R. reports mandatory, are they all detailed, etc? I guess I was just VERY surprised by how thorough and careful my surgeons were... More so than I ever thought was necessary...


  • I applaud you! And, I now want a copy of mine afterwards! I would imagine that this is necessary or mandatory.

    One Love,

  • It had every single detail down to what instrument was used and for what. What position my head was in. Who was in the room. What they did. The weight they used to hold my head down. EVERYTHING. I went to get my medical records today but this wasn't what I was thinking it would be but it was interesting to read.
  • Surgeons are required to write op reports. They are also required to write a history & physical which has to be in your chart before surgery, and a discharge summary when you go home. The H&P and the D/C summary can be done by the PA, but must be authenticated by the surgeon. My op report was 3 pages long for a one-level posterior fusion. I found it very informative as well. That is where I found out exactly what type of hardware and implants I have. I am still amazed that there are people in this world who are so talented that they can fix us Spineys up =D> :X
  • "If it isn't documented, it didn't happen."

    OP reports have to be detailed for many reasons including risk management but especially to be able to code and charge for everything that can be reiumbursed by insurance companies. The documentation has to be there to justify the charges.
  • Do you ask your surgeons office for this report, or call the hospital for it? I would like to get a copy of mine, too.
  • At my hospital you go to medical records and sign a release. They charge 25cents per page and mail it to you in a few days. Now since I work there, they just handed them over, gotta have a few perks don't I :>
  • My daughter works as an RN at the hospital where I had my surgery. Would they give it to her, you think?
  • Joy, not sure. I think you would at least have to sign the release and designate her as the recipient. Good-luck, Sue
  • Everything is documented for many reasons,financail purposes being one of them.If it has not been documented they cannot bill you.Charts make documentation easier for the staff as far as details are concerned.Lists for instruments and supplies used(billing purposes),and of course the protection of Drs,nurses,staff,and patient.

    I saw strange things on a bill once years ago and took it to the attn. of the hospital billing dept.,where after much ado I found out that a mucus recovery system used in the OR-and I was charged 135.00 for,was really KLEENEX.
  • I just went up to medical records, showed an ID, they printed it out in like, 10 seconds, I paid 6 bucks for all the pages and signed for them.

    What I don't get is how like... These reports can be done, but surgeon's can make such screw ups... Is is that they write false reports, or just intentionally generalize so that it's not a lie, but it's not the truth, either? You know, like... If every detail is paid so much attention to... How the heck do people get instruments left inside their body, or the wrong disc removed? Ya know? *Shakes head* I don't get it. Lol.
  • That's good you got your OR notes. It's also helpful to get the CD Disc after any xrays or CT/MRI scans to take to your specalist. That is free to get the disks from radiology so it's good you don't have to carry your films around anymore. It's great to hear that patients are taking an active role to get these results. I work in ER and the only time a release is needed is when we send a fax to another hospital to get the patient's history. Even having an EKG photo copied is given for free in ER, well it is where I work anyway. I miss my job but there is no way I could go back to that busy job with my back the way it is now. Anywas I'm glad you got your result Lo and the Dr. can usually go over it with you although they seem to tell you everything in recovery room where you can barely remember anything he says. Okay take care. Charry
    DDD of lumbar spine with sciatica to left hip,leg and foot. L4-L5 posterior disc bulge with prominent facets, L5-S1 prominent facets with a posterior osteocartilaginous bar. Mild bilateral foraminal narrowing c-spine c4-c7 RN
  • Yes, it is amazing isn't it? In 2006, I had a bladder suspension surgery along with an enterocele/rectocele and tubes tied all in one surgery. I ordered mys urgical report as well and was totally amazed when reading it. But yes, you CAN get the report anytime you want through your hospital's medical records dept. I am going to do the same for my recent ACDF with PEEK cage on 11/6 and read that report as well. I honestly can't wait to read it LOL! Insane!
  • I got a 1 1/2 pp. preliminary report from the surgeon's office at my two-week checkup, then downloaded the medical record release form form the hospital's website and mailed it in for the detailed final surgical and hospital report. I also called them to ask how much it will be. They said the first 20 pp. are free, but they charge some if it is longer. Well, I received my report that was 21 pp long, but they never billed me for the extra page. It probably would have cost more to process a biil than printing the extra page.

    Interesting reading, I can recommend it.

  • Hey there,

    I'm in training to become a Surgical Assistant and it very eye-opening as to what goes into those reports, who is responsible for what, and most importantly-how they make sure instruments, needles, and sponges are not left inside the body.

    The circulating nurse and scrub tech (that's me) have a minimum number of counts that have to be done at certain times with all numbers matching or else an x-ray is needed before you are closed. All sponges now have a strip that shows on film in case they are left in.

    Believe or not, the doctors have no idea of the numbers and have to but 100% faith in those around them that all is right so the doc does not get sued.

    Puts me in a bad place, I know too much of what goes on in surgery, good and bad, from the non-patient side of things and as safe as things are I still worry. Especially since my surgery will be at the VA where I was doing my last rotation :SS

  • Interesting comments, Aimee.

    But, sometimes it is good to be just a little ignorant, on the other hand some of us are helped by knowing exactly what goes on when we are under. Now I wish I would have asked my OS to let my husband video my fusion procedure. That would be neat (and perhaps embarrassing) especially if my behind was exposed!

    I don't know what is your home state, but here where I live in N. Cal. the VA hospital is associated with one of the nationally acclaimed universities (residents, interns rotate, and staff Drs are often on the faculty) and it has a very good reputation. So most likely you will get excellent care.

    Good luck with your surgery!

  • In UK you have to apply in writing to have access to specific information, which I agree with.

    But, while I want to know every detail =)) I also don't want to know because I worry so.
    Does that make sense?

    I get copies of the letters and stuff and they are good summaries of whats happening etc but as for the operation notes...post this operation I had enough remarks made to me in hospital I made me glad I was out of it.

    The anaesthetist was so relieved in the recovery room I was ok (I was rolling in pain at that point) you can't help but wonder what goes on, The surgeon was so pleased i could move my legs like nothing else mattered and then PT said my nerves were all badly inflamed and the inevitable dural tear....

    But documenting, accurately is a skill. You need enough info to recall the incident and not enough that you are confessing your soul. My guess is that more conscientious professionals will document clearly and openly.

    So I do wnat to know, but knbow that he doctor is playing the see how far she gets game without putting thoughts in my head!

    Take Care
  • Yeah, I understand where you're coming from. I guess though it might depend on the outcome of the surgery. Since mine was a success, it was awesome reading the O.R. reports. I don't think they should charge anyone for them, I think you should be offered a copy before you leave the hospital. The only reason I don't think you should have to apply, or pay, or anything like that, is because it's your body... You have the RIGHT to know what goes on with it... But it should be an option, really. That's all I'm saying. If someone doesn't want it, they shouldn't have to hear more information than necessary... But if someone does, they should most definitely have that option... And it should be made easily accessible for them. It was very easy for me to get my reports, but I just hated how I had to pay for it. That was pretty lame. It's like, they probably got like, 70k for my back surgery, and they can't throw a few pages of a report in with it? LOL.

    That would make sense. You're right. The ones who are more conscientious probably do report more clearly and more accurately. So I would go so far as to say anyone with a detailed O.R. report probably had a smart doctor. Hahaha. I actually got one from the Vascular surgeon and a separate one from the Neurosurgeon from the same surgery. It's nice.
  • lol!

    Still, I'm too scared!
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