Describes an operation or surgical procedure - a procedure both manual (using a physician's hands) and operative (using surgical tools or instruments) for the purpose of correcting, repairing, and diagnosing medical abnormalities, defects or diseases.
-ususally dictated by the surgeon or by the assistant
Main seciton of the OP is description of surgical procedure, sometimes called the procedure
-Usually also dictated in the report are the diagnoses before and after the operation - called the preoperative and postoperative diagnoses
-the name of the surgeon, title and date of procedure, the indications for surgery, and surgical findings (upon procedure being performed)
-Includes a sponge count
-Estimation of blood lost during the surgery
=Ends when the patient is taken to the recovery room, and physician will usually state the condition of the patient upon leaving the operating room