How many main sections is an operative report divided into?

An operative report is typically divided into four main sections. These sections are designed to provide a comprehensive overview of the surgical procedure performed, ensuring clarity and thorough documentation. The first section generally includes patient identification details and the procedure performed. The second section outlines the preoperative diagnosis and relevant history. The third section describes the surgical procedure itself, including the steps taken and any notable findings during the operation. Finally, the fourth section contains the postoperative diagnosis and any follow-up instructions or recommendations.

Having a standardized structure allows healthcare professionals to easily find and understand critical information while also adhering to legal and clinical documentation standards. The four sections ensure that all necessary details are covered, which is crucial for maintaining continuity of care and supporting billing and coding practices.