An operative note, or operative report, is the surgeon’s record of an operation: why it was done, what was found, each step taken, and what happens next. Copy the free template, see a laparoscopic cholecystectomy and an incarcerated umbilical hernia repair with mesh, and check what goes in each part, from the findings to the implant lot number.
Blank operative note template
FreeOPERATIVE REPORT Patient: [Name, date of birth, record number] Date of surgery: [Date] Location: [Hospital and operating room] Case type: [Elective, urgent, or emergency] Surgeon: [Name, credentials] Assistants: [Name, role, and what each did, such as camera, retraction, or closure; or none] Supervision: [Supervising surgeon present for the whole procedure or for named parts, when a trainee operated; or not applicable] Anesthesia: [General, spinal, regional block, or local with sedation; anesthesia clinician] DIAGNOSES AND PROCEDURE Preoperative diagnosis: [The diagnosis the operation was planned for] Postoperative diagnosis: [The diagnosis after what was found, or same as preoperative] Procedure performed: [Each procedure as done, with side and approach, and any conversion, such as laparoscopic converted to open] INDICATIONS AND CONSENT Indications: [Short history, exam, key results and imaging, and why surgery now] Consent: [Risks, benefits, and alternatives discussed; what was agreed if plans change, such as conversion or a bowel resection; who signed and when] FINDINGS Findings: [The organ and the disease, its extent, anatomy that mattered for safety, unexpected findings, and pertinent negatives] DESCRIPTION OF THE PROCEDURE Identification and positioning: [Identity and site confirmed, position, padding, warming, and compression devices] Antibiotic: [Drug, dose, and time given, or not indicated] Prep and drape: [Hair removal if any, skin prep, drying time, and drape] Time out: [Time, and that patient, procedure, side, antibiotic, and equipment were confirmed] Incision and access: [Site and length; for laparoscopy, entry technique, port sizes and sites, and insufflation pressure] Steps: [Each step in order, what was seen, and the reasoning at key decisions] Hemostasis and specimen removal: [How bleeding was controlled, irrigation, and how the specimen was taken out] Closure: [Each layer, with suture type and size, and the skin] Local anesthetic and dressing: [Drug, strength, and volume; dressing applied] Times: [Incision and closure times] CASE DETAILS Estimated blood loss: [Volume in mL, agreed with anesthesia] Fluids and blood products: [Crystalloid volume, blood products in units, and urine output if measured] Drains: [Type, size, site, and what it drains to, or none] Implants: [Device, size, manufacturer, reference and lot numbers, or none] Specimens: [Each specimen and where it went: pathology, culture, or discarded per policy; or none] Counts: [Sponge, needle, and instrument counts correct, and who confirmed; or the discrepancy and what was done] Complications: [None, or what happened, when, and what was done] Condition: [Extubated, awake, and stable, or otherwise] Disposition: [Recovery room, then ward, intensive care, or home] POSTOPERATIVE PLAN Plan: [Diet, activity, pain control, antibiotics, VTE prophylaxis, drains, wound care, and home medicines to restart or hold] Watch for: [Signs that need a call to the surgeon, or a return to the operating room] Follow-up: [Clinic visit, pathology review, and who will tell the patient the results] Family update: [Who was told, by whom, and when] BRIEF OPERATIVE NOTE Entered: [Date and time, before the patient leaves recovery, when the full report will be dictated later; or not needed] Contents: [Surgeon and assistants, procedure, findings, estimated blood loss, specimens, and postoperative diagnosis] SIGNATURE Dictated or written: [Name, date and time] Signed: [Surgeon name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Acute care surgery list, community hospital, general anesthesia
Daniel Mercer, born April 2, 1974, male. Record number 4419027. November 6, 2026, operating room 4. Urgent case. Surgeon: Dr. Amara Nwosu, general surgeon. Assistant: Dr. Kevin Liu, senior surgical resident, who ran the camera, placed the ports, and closed the skin. Dr. Nwosu was scrubbed for the whole procedure. Anesthesia: general with endotracheal intubation, Dr. Sofia Marin.
Preoperative diagnosis: acute calculous cholecystitis. Postoperative diagnosis: acute calculous cholecystitis, with a distended, edematous gallbladder and a stone impacted in Hartmann’s pouch; no gangrene or perforation. Procedure performed: laparoscopic cholecystectomy. No cholangiogram: liver tests and the common bile duct were normal.
52-year-old man with 36 hours of constant right upper quadrant pain and vomiting. T 38.4 °C (101.1 °F); Murphy sign positive. WBC 14.2; bilirubin, liver enzymes, and lipase normal. Ultrasound: gallstones with one fixed in the neck, wall 6 mm, pericholecystic fluid, sonographic Murphy sign, common bile duct 4 mm. Mild acute cholecystitis, Tokyo Guidelines grade I. On ceftriaxone since admission. Early laparoscopic cholecystectomy recommended during this admission. Consent: bleeding, infection, bile leak, bile duct injury, retained stones, conversion to open, and a subtotal cholecystectomy if the anatomy couldn’t be seen safely. Signed November 5.
Distended, tense gallbladder with a thick, edematous wall; omentum stuck to the fundus. Stone impacted in Hartmann’s pouch. No gangrene, perforation, or pus. Critical view of safety achieved: hepatocystic triangle cleared of fat and fibrous tissue, lower third of the gallbladder off the cystic plate, and only two structures, the cystic duct and the cystic artery, entering the gallbladder. Cystic duct about 3 mm. Liver normal.
Identity and procedure confirmed. Supine, both arms on padded boards; compression devices on both legs and forced-air warming. Orogastric tube placed after intubation. Ceftriaxone 2 g IV, his daily dose, at 07:40. Skin prepped with chlorhexidine-alcohol, dried for 3 minutes, and draped. Time out at 08:02: patient, procedure, antibiotic, and ultrasound images confirmed. Open entry at the umbilicus, 12 mm port, pneumoperitoneum at 15 mmHg. Three 5 mm ports under vision: one epigastric, two right subcostal. Reverse Trendelenburg, left side down. Omentum swept off the fundus. The gallbladder was too tense to grasp, so it was decompressed with a needle aspirator: 60 mL of cloudy bile, sent for culture. Fundus retracted over the liver and Hartmann’s pouch drawn laterally. Peritoneum opened on both sides of the hepatocystic triangle, the triangle cleared, and the lower third of the gallbladder taken off the cystic plate. Critical view confirmed by both surgeons and photographed from the front and the back before any clip was placed. Cystic duct and cystic artery each clipped twice on the patient side and once on the gallbladder side, then divided. Gallbladder taken off the liver bed with hook cautery, close to its wall. Liver bed dry, clips secure, no bile in the field; right upper quadrant irrigated until clear. Gallbladder removed intact in a retrieval bag through the umbilical port; no stones spilled. Umbilical fascia closed with two figure-of-eight 0 absorbable sutures. Ports removed under vision with no bleeding, and the pneumoperitoneum released. Bupivacaine 0.25%, 20 mL, into the port sites. Skin closed with 4-0 absorbable subcuticular sutures and skin glue. Incision 08:05; closure 09:14.
Estimated blood loss: 20 mL. Fluids: 900 mL lactated Ringer’s; no blood products; no urinary catheter. Drains: none. Implants: none. Specimens: gallbladder with stones, to pathology; bile, to microbiology for culture. Counts: correct twice, confirmed by the scrub and circulating nurses. Complications: none. Condition: extubated in the room, awake and stable. Disposition: recovery, then the surgical ward.
Diet as tolerated tonight; walk this evening. Acetaminophen 1 g every 6 hours and ibuprofen 400 mg every 8 hours, with oxycodone 5 mg if needed. Stop ceftriaxone: no antibiotics needed once the gallbladder is out in mild cholecystitis. Compression devices until walking. Restart lisinopril tomorrow. Home tomorrow if eating and comfortable on tablets; may shower tomorrow. Watch for: fever, jaundice, or pain that gets worse instead of better, which could mean a bile leak; call the surgical team. Follow-up: clinic in 2 weeks for the pathology and the bile culture. His wife was updated by Dr. Nwosu by phone at 09:35.
Dictated by Dr. Amara Nwosu on November 6, 2026, at 09:40. Signed by Amara Nwosu, MD, general surgery, on November 6 at 14:10.
Emergency operating room, regional hospital, evening, general anesthesia
Linda Ferreira, born January 19, 1962, female. Record number 6620381. November 8, 2026, emergency operating room. Emergency case. Surgeon: Dr. Rachel Stein, general surgeon. Assistant: Ana Ruiz, RN first assistant, for retraction and suction. Anesthesia: general, with rapid sequence induction and endotracheal intubation, Dr. Paul Okeke.
Preoperative diagnosis: incarcerated umbilical hernia containing small bowel, with partial small bowel obstruction. Postoperative diagnosis: incarcerated umbilical hernia, 3 cm fascial defect, containing small bowel and omentum; bowel viable after release; congested omentum. Procedure performed: open umbilical hernia repair with preperitoneal polypropylene mesh, and excision of congested omentum.
64-year-old woman with an umbilical hernia for 3 years, reducible until this morning. 14 hours of a painful, firm bulge that won’t go back, with nausea and 2 episodes of vomiting. Type 2 diabetes on metformin, hypertension, BMI 34, weight 92 kg. Tender, irreducible 5 cm lump with no skin redness; abdomen otherwise soft, no peritonitis. WBC 11.8; lactate 1.4 mmol/L. CT: 3 cm umbilical defect holding a loop of small bowel, with dilated bowel upstream to 3.2 cm; bowel wall enhancing; no free fluid or free air. One gentle attempt at reduction with analgesia failed. Nasogastric tube placed in the emergency department, 300 mL out. Consent: open repair with mesh; risks of infection, seroma, bleeding, recurrence, bowel injury, and mesh infection that could need removal. If bowel needed resection: a larger incision, and a repair without permanent mesh. Signed at 18:20.
3 cm fascial defect with a thick sac, tight at the neck. Inside: a 10 cm loop of small bowel and a tongue of omentum. The bowel was dark red with a constriction ring at first. After the neck was released and 10 minutes under warm, wet packs, it was pink and shiny, with peristalsis and pulsation in the mesentery; serosa intact at the ring, not thinned. Viable, so no resection. Omentum dark and congested. Clear, odorless fluid in the sac. No other midline defect felt.
Identity, consent, and procedure confirmed. Supine, arms out; compression devices on both legs and forced-air warming. Nasogastric tube aspirated before rapid sequence induction. Cefazolin 2 g IV at 18:52. Skin prepped with chlorhexidine-alcohol, dried, and draped. Time out at 19:01: patient, procedure, antibiotic, and mesh in the room confirmed. 5 cm curved incision below the umbilicus. Sac freed from the umbilical skin and fat down to the fascial edge, then opened. The neck was too tight to free the contents, so the fascial ring was cut 1 cm upward, leaving a 4 cm defect. Bowel and omentum assessed as in the findings. Omentum tied with 2-0 absorbable ties and excised; bowel returned to the abdomen. Sac excised, and the peritoneum closed with a running 3-0 absorbable suture so the mesh would not touch the bowel. Preperitoneal space opened 4 cm beyond the defect edge on all sides. No bowel was opened, so a permanent synthetic mesh was used. Flat polypropylene mesh trimmed to a 10 cm circle, laid flat in the preperitoneal space with at least 3 cm overlap on every side, and fixed at 4 points with 2-0 polypropylene sutures. Fascia closed over it transversely with interrupted 0 slowly absorbable monofilament sutures, without tension. Umbilical skin tacked to the fascia with 3-0 absorbable suture. Hemostasis checked and the wound irrigated. Fat closed with 3-0 absorbable sutures, skin with 4-0 absorbable subcuticular sutures. Bupivacaine 0.25%, 20 mL, into the wound. Gauze and a light pressure dressing. Incision 19:06; closure 20:14.
Estimated blood loss: 30 mL. Fluids: 1,400 mL lactated Ringer’s; no blood products; urine output not measured. Drains: none. Implant: flat medium-weight polypropylene mesh, 15 × 15 cm sheet trimmed to a 10 cm circle; REF PPM-1515, lot 26H0417, expiry August 2029; implant sticker in the record. Specimens: hernia sac and omentum, to pathology. Counts: correct twice, confirmed by both nurses. Complications: none. Condition: extubated in the room, awake and stable. Disposition: recovery, then the surgical ward.
Nasogastric tube out in recovery if no nausea. Clear fluids tonight, then diet as bowel function returns. Acetaminophen and ibuprofen on schedule, oxycodone if needed. Glucose checks before meals and at bedtime; hold metformin until eating normally. Enoxaparin 40 mg subcutaneously daily from tomorrow morning; compression devices until walking. No antibiotics after surgery. Light activity; no heavy lifting for 4 weeks. Watch for: pain out of proportion, fever, a fast heart rate, vomiting, or a rising lactate over the next 48 hours, which could mean the bowel has failed after all; call Dr. Stein at once. Follow-up: clinic in 2 weeks for a wound check and the pathology. Her daughter was updated by Dr. Stein by phone at 20:40.
Entered by Dr. Stein in recovery at 20:32, before transfer to the ward: surgeon and assistant; open umbilical hernia repair with preperitoneal mesh and excision of omentum; viable small bowel after release; estimated blood loss 30 mL; hernia sac and omentum to pathology; mesh lot 26H0417; postoperative diagnosis as above.
Full report dictated by Dr. Rachel Stein on November 8, 2026, at 21:10. Signed by Rachel Stein, MD, general surgery, on November 9 at 07:45.
Who the patient is, when and where the operation took place, and everyone who did it. Say what each assistant did, not just who was in the room.
Avoid: “Assistant: Dr. Liu” with no role. Write what they did: camera, retraction, port placement, or closure.
The diagnosis the operation was planned for, the diagnosis once you’d seen inside, and the name of each procedure as it was done.
Avoid: Copying the booked procedure. If you converted to open or added a step, name what was actually done.
Why this patient needed this operation now, and what they agreed to, including what you’d do if the plan had to change.
Avoid: “Risks and benefits discussed.” Name the main risks you covered, and any change of plan the patient agreed to in advance.
What you saw and felt. Many readers go straight to this section, so write it to stand on its own.
Avoid: Leaving the findings inside the description. Give them their own section, so the next team doesn’t have to read every step to learn what you found.
What you did, in order, written so another surgeon could follow it, or find their way at a later operation.
Avoid: Pasting a standard description. Read it against this case line by line, and take out every step you didn’t do.
The short list that recovery staff, the pathologist, and anyone tracing a device will look for.
Avoid: “EBL minimal.” Give a number. If the hemoglobin falls tonight, the next team needs something to compare it with.
What the ward team, and the patient, should do next, and what would make you want a call.
Avoid: “Routine postoperative care.” Say what routine means for this patient, such as stopping antibiotics, or what would mean a return to the operating room.
If the full report won’t be in the record before the patient leaves recovery, enter a brief operative note first. Sign the full report once it’s typed and checked.
Avoid: Dictating days later from memory. Dictate on the day, and read the transcription before you sign it.
A standard description that says “drain placed” or “cholangiogram normal” when neither happened is a false record. Delete the steps you didn’t do, and add the ones you did, such as decompressing a tense gallbladder.
If you found gangrene, a perforation, or a different disease, the postoperative diagnosis changes. Coding, the pathologist, and the next team all read it.
Name the three things you saw before clipping, and note any photos saved. If you couldn’t reach the critical view, write what you did instead, such as a cholangiogram or a subtotal cholecystectomy.
Mesh and other implants are traced by lot number when there’s a recall. Put the device, size, manufacturer, reference number, and lot in the report, and the sticker in the record.
A torn gallbladder with spilled stones, a bowel injury that was repaired, or bleeding that needed a transfusion belongs in the report, with what you did. Spilled stones left behind can cause an abscess months later, so say how many were retrieved.
If the full report is dictated later, the ward team still needs the procedure, findings, blood loss, and specimens tonight. Enter a brief operative note before the patient moves on.
Vero Scribe writes the operative report in your template from your dictation after the case. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Write or dictate it as soon as the operation ends, while the details are fresh. Start with the patient, the team, and the diagnoses before and after surgery. Then give the indications and consent, the findings, and a step-by-step description of what you did in this case. Finish with blood loss, fluids, drains, implants, specimens, counts, complications, the patient’s condition, and the plan.
Hospital standards usually ask for at least the surgeon and assistants, the procedure performed, a description of it, the findings, estimated blood loss, specimens removed, and the postoperative diagnosis. Most surgeons also record the anesthesia, indications and consent, fluids, drains, implants with lot numbers, counts, complications, the patient’s condition, and the plan. Check your hospital’s bylaws for anything else it requires.
Usually, yes. Op note, operative note, and operative report all mean the surgeon’s record of the operation. Some hospitals use “op note” for the brief note written right after surgery, and “operative report” for the full one dictated later.
A short note entered right after surgery when the full report won’t be in the record before the patient leaves recovery. Many hospitals require one then. It lists the surgeon and assistants, the procedure, findings, estimated blood loss, specimens, and the postoperative diagnosis, so the next team has what they need while the full report is dictated and typed.
Name the three things you saw before clipping anything: the hepatocystic triangle cleared of fat and fibrous tissue, the lower third of the gallbladder separated from the liver bed, and only two structures, the cystic duct and the cystic artery, entering the gallbladder. Many surgeons save photos from the front and the back. If you couldn’t reach it, write what you did instead, such as a cholangiogram or a subtotal cholecystectomy.
An operative note records an operation in the operating room, usually with anesthesia, a team, and a full description. A procedure note covers a bedside or clinic procedure, such as a central line, a chest tube, or a skin biopsy. It’s shorter, with the same core: indication, consent, time out, technique, findings, complications, and the plan.
Yes. Copy it, or download it as a Word or text file. No account needed.
The surgeon’s consult in the emergency department or clinic: the question, abdominal and hernia exam, results with a severity grade, the decision to operate, consent, and timing.
The surgical team’s note after an operation: pain, eating, bowels, urine, walking, wound, drains, labs, and discharge criteria.
Dictate after the case, and review a structured operative note.
Consults, clinic visits, and follow-up notes, drafted for your review.
Sign in, time out, and sign out, with who confirmed each check.
The codes used most often in general surgery.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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