Hospital and clinic documents
Operative report explainer
An operative report is the surgeon's record of an operation, written in a fixed order and in technical language. Add yours below to see each heading explained and the description of the procedure restated step by step.
Explain your operative report
- 1. Add itDrop a PDF, take a photo or paste the text.
- 2. Check itPersonal details are removed on your device. You approve what is sent.
- 3. Read itSummary, table of results, terms and questions to ask.
The explainer opens on its own page with no adverts and no outside scripts. Your file is read on your device and is never uploaded.
What you get
- Each heading of the report identified and restated.
- The procedure name broken into its parts and explained.
- Abbreviations such as EBL and PACU written out.
- Questions to ask your surgeon at follow-up.
Headings in an operative report
- Preoperative and postoperative diagnosisWhat was expected, and what was found
- Procedure performed and type of anaesthesia
- FindingsWhat the surgeon saw during the operation
- Description of procedureThe steps, in order
- EBLEstimated blood loss
- Specimens, drains, implants and complications
What this tool cannot tell you
An operative report describes what was done, not how recovery will go. MedicDecode restates the report and cannot tell you whether the operation was a success or what to expect afterwards. Follow the instructions you were given on discharge, and contact your surgical team if you have concerns about your recovery.
Common questions
Why are there two diagnoses, before and after?
The first is what the surgeon expected going in. The second is what was confirmed during the operation. Often the report simply says same.
What does specimens sent to pathology mean?
Tissue removed during the operation was sent to a laboratory to be examined. That result comes later, in a separate pathology report.
What is EBL?
Estimated blood loss: the surgical team's estimate of how much blood was lost during the operation.
Words you may see on this report
Tap a word for its plain-English meaning, an example line and what it does not mean.
- Dialysis
Dialysis is a treatment that removes waste and extra fluid from the blood when the kidneys can no longer do this well enough.
- Directly observed therapy
Directly observed therapy (DOT) means a health worker watches you take each dose of a medicine, most often for tuberculosis treatment.
- Discharge summary
A discharge summary is a document written when you leave hospital that explains why you were there, what was done, and what happens next.
- Follow-up appointment
A follow-up appointment is a planned visit after a test, treatment or hospital stay to check progress and decide next steps.
- Hemodialysis
Hemodialysis is a treatment where a machine filters the blood to remove waste and extra fluid when the kidneys cannot do it well enough.
- Nil by mouth
Nil by mouth means a person should not eat or drink anything, usually before surgery, a procedure or certain tests.
- Palliative
Palliative means care or treatment focused on easing symptoms and improving quality of life, rather than on removing the illness itself.
- Referral
A referral is when one health professional asks another, usually a specialist or service, to see you or carry out a test.
- Triage
Triage is the process of sorting patients by how urgently they need care, so the most urgent are seen first.
- Vital signs
Vital signs are basic body measurements, such as heart rate, blood pressure, breathing rate, temperature and oxygen level.