Operation notes

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These form part of the medical record and should also serve as a means of communication to other surgeons. It should provide sufficient detail to given an idea of what was done during the procedure.

The Royal College of Surgeons of England suggest in their Good Surgical Practice (2002) document that the following should be included:[1]

  • Date and time
  • Whether elective/emergency procedure
  • Names of the operating surgeon and assistant
  • Operative procedure carried out
  • Type of incision
  • Operative diagnosis
  • Operative findings
  • Any problems/complications
  • Any extra procedure performed and the reason why it was performed
  • Details of tissue removed, added or altered
  • Identification of any prosthesis used, including the serial numbers of prostheses and other implanted materials
  • Details of closure technique
  • Postoperative care instructions
  • Signature

Other useful aspects include:

  • Indication for surgery
  • Positioning
  • Pre-operative preparation, e.g. skin antisepsis, catheterisation, etc.

References

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