Surgical Record

[msuscottie]

Hi Guys,

A while back I asked a question about getting copies of my medical records so that I can read about what happened during my surgery. You guys had mentioned that there was something called "surgical records" I think? that I could get a copy of from my Neurosurgeon? Can you remind me what it is that I should ask him for? I have an appointment with him on Wednesday and I'd like to get a copy of whatveverrecord it is   

Thanks

[HeadCase2]

Scott,
  The "Surgical Record" is correct.  It's a description of what happened during surgery, what surgeons were involved,  step by step, and any notable things that occurred.  I asked my Neurosurgeon's admin person for a copy of my Surgical Record.  It was an interesting read.
  Maybe we could start a thread listing some surgical records for general interest.
Regards,
 Rob

[Joef]

they (the doctors) "report" to fill out after each surgery .. and it becomes part of the record .. they dont always give you a copy unless you ASK for it .. and commonly has details you did not know about !! it will have doctor lingo and such ...

normally they will give it to you for free WHILE you are still at the hospital .. but afterwards will charge you a small "processing" fee ...

[krbonner]

It may also be called a procedure or operative report.  I just got copies of mine last week, and I'm really glad I did.  It included two pages of dictated notes from each surgeon, plus additional pages documenting everything else that happened in the OR (nurses in/out, equipment used, etc.). 

Katie

[Battyp]

and you might need to check with medical records with the hospital instead of your doctors office to get it.
Does make for some interesting reading...they did a sacrifice on my vestibular nerve...they've yet to tell me what type of dance they did and if they had to offer up a virgin or a chicken  LOL

[Pembo]

My doc's office just pulled them up on the computer and printed them out for me. There was A LOT of medical jargon and I spent quite a bit of time in front of my computer looking up all the big words. It was a very interesting read. I learned that my tumor was a bleeder.

[msuscottie]

Did your Dr. get offended when you asked for the record? Like you were checking up on him or something?

[krbonner]

Did your Dr. get offended when you asked for the record? Like you were checking up on him or something?

I would hope the doctor wouldn't be offended!  I've always gotten copies of all my MRI films, test results, reports, audiology exams, and anything else that's documented so I always have my own copies if I ever need to show them to another doctor.  It's your absolute legal right to have copies of all this stuff.  And depending on how big your doctor's practice is, you may have to go through a Medical Records department so your doctor would never even know you requested it!

Katie

[Captain Deb]

Hey Batty--In true West Indian fashion, mine used a goat. My request.
Capt Deb

[FlyersFan68]

I recently had my records faxed and was extremely interesting reading. I knew when and how most of the procedure was performed. I wanted to have everything in case my surgeon relocates one day or if I decide to go elsewhere should another problem arise. DEFINITELY make sure you follow through with this!

[msuscottie]

I asked my Dr about this yesterday and he said I can get this my calling the Medical records department at the hospital. He referred to them as "Operative Notes." My question is ... Is there anything else I should get a copy of? Any point in getting a copy of my whole medical record? Would the operative notes be right in there anyway?

[FlyersFan68]

That was it..."Operative Notes". Who knows where these doctors will be in 20 years. Maybe even retired. Twenty years for guys like us only puts us in our late 40's or 50's.

[krbonner]

I asked my Dr about this yesterday and he said I can get this my calling the Medical records department at the hospital. He referred to them as "Operative Notes." My question is ... Is there anything else I should get a copy of? Any point in getting a copy of my whole medical record? Would the operative notes be right in there anyway?

I requested copies of the Operative Report, Pathology Report (which was also interesting reading), discharge summary (my PCP wanted a copy of this), radiology reports, lab results (a good bloodwork baseline if anything ever comes up in the future), and audiology reports.  But I personally like having cpies of all this stuff so if it's ever needed in the future I don't have to go through the effort of getting it at that point.

Katie

[tcrnko]

You might also ask for a copy of the hospital record, nurses notes, etc for your stay after surgery.  These also can have information on how you tolerated anesthesia, the ICU experience, etc.

[KatyB]

Hi - as a medical transcriptionist by profession and also one who has been through AN surgery, I can tell you to definitely get a copy of all of your records.  I type these things day in and day out and I was still surprised by some things in my op report.  And like someone else said, you may need it someday when those doctors are long gone.  It's also a good idea to keep your original MRI and the most recent one.  These records are yours and no one should give you a hard time about getting copies.