Which type of report includes the names of the surgeon and assistants, date, duration, and description of the procedure performed?

Prepare for the RHIT Domain 1 Test. Study with flashcards and multiple choice questions with hints and explanations. Get ready for your certification exam!

The operative report is a detailed document that captures critical information pertaining to a surgical procedure. It explicitly includes the names of the surgeon and the surgical assistants, the date the procedure was performed, the duration of the surgery, and a comprehensive description of the procedure itself. This report serves as a vital component of a patient’s medical record, providing both clinical details and a narrative that can inform further treatment decisions, follow-up care, and documentation for billing purposes. The accuracy and thoroughness of an operative report are essential for maintaining quality care and effective communication among healthcare providers.

In contrast, an anesthesia report primarily focuses on the anesthesia administered, patient monitoring, and any complications related to anesthesia, lacking detailed procedural information. A laboratory report centers on laboratory test results and their interpretations, while a pathology report details the examination of tissue specimens but does not cover the surgical aspects and personnel involved. Each type of report serves a specific purpose and contains distinct information relevant to different aspects of patient care.

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