Should an auditor expect to see operative notes from the surgical assistant?

In the context of medical auditing, it is important to recognize the role of various team members during a surgical procedure. Operative notes are typically the responsibility of the primary surgeon, as they provide a detailed account of the procedure performed, the findings, and any complications that may have arisen.

Surgical assistants, often physician assistants or other surgical technicians, contribute to the surgery and may provide their own notes or documentation, but it is not standard practice to require their operative notes as a matter of course. Their notes might be included if relevant, but they are not mandatory or required for auditing purposes. Typically, the primary focus of an audit will be on the primary surgeon’s documentation since it holds the authoritative account of the operative procedure.

This dynamic underscores why it is expected that operative notes from surgical assistants are not a routine requirement; they are supplementary and not always included in a thorough audit unless a specific situation or context calls for them. In most cases, auditing relies on the primary surgeon’s documentation to assess the quality and completeness of the care provided. This understanding helps streamline the auditing process by focusing on the most relevant and critical documentation.