Are doctors required to keep detailed operative notes for each patient even if they do a large amount of the same surgery?

Question

I found a discussion on this site where women who all had surgery with the same surgeon had seen each others surgical notes and found out that they were all the same - word for word. Same pre op evaluation, same surgical notes, same post op. Several of them are having post surgery complications but there is nothing in the surgical notes specific to their surgery. The doctor boasts of doing 600 surgeries per year and apparently is cutting and pasting surgical notes for all surgeries Is this normal?

Anita Patel, MD, FACS · Answer

Regarding operative notes- some surgeons dictate a new note after each surgery, and others use a template. Some surgeons include a very high level of detail in the notes and include surgical reasoning, whereas other surgeons simply list the steps performed during the procedure without additional narrative. Any of these methods are acceptable as long as the operative note is specific to that procedure and that patient, and makes clear what was done.  Even if using a template, certain areas have blanks or a drop-down menu to choose from, so that each note should still be specific to the patient. That being said, if a surgeon does 600 of the same procedure each year, then it is very likely she/he has come up with a specific set of steps that she/he uses for each patient having that procedure. Unless there is something unusual about a particular patient's anatomy or needs, the operative notes could very well read the same. In that sense, the operative note may be the same because she/he literally does it the same way every time. I can see how it can appear suspicious, but in and of itself, it does not mean anything. Also, if a patient is having a postoperative complication, the operative note may or may not be useful in determining the cause. One would really have to look at the whole picture, which would include each patient's medical history, starting physical exam, what procedure was done and how, when the complication started versus when it was recognized, etc. Regarding the preop evaluation and postop notes- these to me would be more concerning if they read the same word for word for each patient. The content of the notes comes down to how detailed the surgeon's note-taking is. I personally include a lot of details about each patient in the preop and postop notes, but not each surgeon does. Some surgeons will have a note that simply reads "normal postop exam", whereas others may include details about the dressings, drains, swelling, skin color, etc. Also, part of the preop eval includes personal past medical history, family history, physical exam with measurements if applicable, etc, which is highly unlikely to be the same patient to patient. If all components of each patients chart were the same word for word before, during, and after surgery, I agree this is concerning.

Michel C. Samson, MD · Answer

Your doctor may have been using "templates", which can be helpful in improving the efficiency of notetaking chores, by repeating routine and consistently performed procedures, evaluations and postop care notes. This is fine as long as the care rendered actually was the same- for example procedures or portions thereof which are done the same way every time, can be recorded the same way in the notes. Any meaningful differences between patients, however, should be noted.Some doctors keep very detailed operative notes, others are more minimalist in their recording, and neither is truly reflective of the quality of care actually received. Nevertheless, the medical record should accurately reflect the care actually rendered to each individual patient, and should be designed to be helpful in communicating what was done to other members of the healthcare team, who are participating in, or continuing on the patient's healthcare.

Are doctors required to keep detailed operative notes for each patient even if they do a large amount of the same surgery?

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Are doctors required to keep detailed operative notes for each patient even if they do a large amount of the same surgery?

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Everything you need to know about Lip Lift

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