Operative Note Template

Pre-Op Diagnosis

[State the pre-operative diagnosis for the patient, including the primary condition or reason for surgery.]

Post-Op Diagnosis

[State the post-operative diagnosis, which is typically the same as the pre-operative diagnosis unless additional findings are made during surgery.]

Complications

[Document any complications that occurred during the procedure or state if there were none.]

Procedure

[Describe the surgical procedure performed, including any additional procedures conducted during the operation.]

Disposition

[Describe the patient's condition at the end of the procedure, including their destination (e.g., recovery room) and whether they were extubated and stable.]

Surgeon

[Provide the name of the primary surgeon performing the procedure.]

Assistants

[List the names or roles of any assistants involved in the surgery, such as residents or medical students.]

Anesthesia

[Specify the type of anesthesia used during the procedure, such as General Endotracheal Anesthesia (GETA).]

EBL (Estimated Blood Loss)

[Document the estimated amount of blood loss during the procedure, typically noted as minimal, moderate, or a specific volume.]

UOP (Urine Output)

[Indicate whether urine output was monitored during the procedure and, if so, provide the amount or state if it was unmonitored.]

IVF (Intravenous Fluids)

[Record the type and volume of intravenous fluids administered during the procedure.]

Findings

[Describe the intraoperative findings, including any abnormalities, anatomical observations, or results from intraoperative imaging such as cholangiograms.]

Specimens

[List any specimens collected during the procedure and their destination, such as pathology.]

Drains

[Note whether any surgical drains were placed during the procedure and their type or state if none were used.]