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- Nitin Goyal, Claudio Diaz-Ledezma, Mohan Tripathi, Matthew S Austin, and Javad Parvizi.
- Anderson Orthopaedic Clinic, Alexandria, Virginia, USA.
- J Arthroplasty. 2012 Jun 1;27(6):1023-6.
AbstractAn operative note is a vital component of a patient's medical-legal record, permitting the surgical team to safely administer perioperative care. Despite this critical function, operative note contents are neither standardized nor regulated; this is especially concerning in orthopedic surgery. As younger patients undergo total hip arthroplasty (THA) and outlive their prostheses, the need for revision THA cannot be ignored. Surgeons performing primary THA must be cognizant to record detailed implant characteristics to ensure that if necessary, the revision surgeon will have all pertinent information to optimally treat the patient. Our survey of operative notes reveals the dismal nature of component documentation during primary THA; implementation of a standardized procedure-specific operative note guideline may minimize incomplete dictations and drive surgeons to include all pertinent information.Copyright © 2012 Elsevier Inc. All rights reserved.
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