Surgery Report

Subject to modification by the VTH Section Heads without approval.

Policy

The Surgery Report documents surgical procedures or operations and shall be completed for those requiring anesthesia. (For minor surgeries such as, cutaneous biopsies, minor debridements, minor suturing, minor excisions of cutaneous or subcutaneous masses, a surgical report may not be required).

Guidelines

The Surgery Report shall contain at minimum, the following elements: 

• An accurate description of the surgical procedures including duration and identity of the surgeon*
• Description of findings
• Type of closure
• Description of any complications
• Tissues sent to pathology

The Surgery Report is completed in the electronic Medical Record and e-signed by a veterinarian by entering a PIN within 24 hours following surgery. A veterinary student may initiate and save a draft of the report; only the veterinarian may e-sign these reports.

*Required by the American Animal Hospital Association

Procedure (if applicable)

The Surgery Report will no longer be printed and signed for inclusion in the paper record. Before the report is e-signed, it may still be edited. Once e-signed, it may only be updated by adding an addendum, which does not change the original entry. To correct an error in a report that has been e-signed, it must be retracted and re-entered. Retracting the report removes it from public view while maintaining an unobliterated document that may be accessed by Administrators. To have a report retracted, send an email to Medical Records at medrec@vetmed.illinois.edu (include the specific reason for retracting the report for auditing purposes).

Audits on Surgery Report notes will periodically be conducted.

Surgery Reports not e-signed in less than 7 days, by default setting in the hospital information system, will be locked. If the report was auto finalized before review by the supervising veterinarian, the veterinarian shall write an addendum to the report confirming approval. If the veterinarian does not agree with the content the report may be retracted and rewritten.

Definitions (if applicable)

Locked: Reports by default setting within the hospital information system may be set to be locked within a given number of days. Once the report is locked it is no longer editable. An addendum may be added to the report, or the report may be retracted from view and rewritten.

Veterinary Teaching Hospital (VTH): The collective clinical services of the Large Animal Clinic, Midwest Equine, the Small Animal Clinic, and the Veterinary Medicine South Clinic.