Fact · Dictation for work and study
Medicare's hospital surgical services rules require an operative report describing the techniques, findings and tissues removed or altered, written or dictated immediately after surgery and signed by the surgeon.
Checked against its source on October 16, 2026
In the source's own words
“An operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon.”
42 CFR 482.51 Condition of participation: Surgical services, Legal Information Institute, Cornell Law School (text of the Code of Federal Regulations), n.d., Paragraph (b)(6).
Open the original- What it measures
- The operative report is one of the standard report types a medical transcriptionist types from a surgeon's dictation.
- What it does not show
- It applies to Medicare-participating hospitals, and the signature requirement is the surgeon's. Other facilities and specialties may have their own local rules.