Yes, according to Joint Commission standards, the surgeon's operative report must be written or dictated and filed on the patient's health record.
This report should include detailed information about the patient's condition before and after the procedure, the type of procedure performed, the surgical findings, the postoperative care and any other pertinent information.The Joint Commission is an independent, not-for-profit organization that accredits and certifies more than 21,000 health care organizations and programs in the United States. Joint Commission standards are the basis of an objective evaluation process that can help health care organizations measure, assess and improve performance. These standards are evidence-based and cover a wide range of topics related to the quality and safety of patient care. The standards are developed with input from health care professionals, consumers, government agencies, and other experts. The Joint Commission reviews and updates its standards regularly to ensure they reflect the best practices and industry standards.
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