Specific details of surgical or high-risk procedure

Reference no: EM133724256

Question

This part of the health record documents the specific details of a surgical or high-risk procedure. This report will include findings, procedural method, biopsies, or specimens taken; both preoperative and postoperative diagnosis; and the name of the surgeon. It is written/dictated immediately after the procedure and placed in the patient's medical record to allow the next healthcare provider to manage the patient during the postoperative period.

Reference no: EM133724256

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