OPERATIVE 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]