Considerations about the operation note

Abstract

The operation note is an official document that is an indispensable part of the clinical history. Despite the fact that medical (care, teaching and investigative), legal and administrative functions are attributed to it, it frequently does not meet the specificities required in the wording. The permanent and continuous improvement of the professional performance of surgeons demands the rescue of the specificities for the preparation of such an important document. It is considered a specific professional skill for physicians in surgical specialties, as it is part of routine surgical practice and includes quantitative (formal and substantial) and qualitative (informational content) aspects, of mandatory compliance by specialists and residents in training. It constitutes an individual responsibility that must be controlled by directors and teachers of each surgical service. This work expresses the author's position on the necessary rescue of the quality of the preparation of the operation note as an essential part of the safety of the surgical patient.

Keywords

• cirujanos
• docentes
• especialidades quirúrgicas
• gestión de la calidad total
• médicos
• pacientes
• informe operatorio.