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O.R. reports...

LoLLo Posts: 694
edited 06/11/2012 - 7:25 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.
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  • 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.
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  • 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.
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