11/13/24, 7\:41 PM Guide | Writing an operation note

Writing an operation note

Table of contents

Introduction

The operative record serves as an important reference for clinicians to recall the details of a patient's surgical procedure and
plan future management. It is therefore crucial that an accurate and comprehensive record is documented following surgery.
The Royal College of Surgeons of England has published a standard that should be adhered to for all operative records.
1
The general overview of an operative record is as follows\:
Patient details
Procedure details
Operative details
Post-op care instructions
Sign-o

Patient details

The patient's details should be checked to ensure their accuracy and documented clearly including\:
Full name
Date of birth (dd/mm/yyyy)
Hospital number
NHS number

Procedure details

It is important to accurately document the circumstances surrounding the operation, including the indication, setting and the
members of sta
Date and time of the procedure (e.g. 14\:30)
Location of the procedure (e.g. theatre #3)
Elective or emergency procedure
Indication for the procedure
Name of the procedure
Operative
Operating surgeon(s)
Assistants (e.g. registrars, medical students)
Anaesthetist and anaesthesia assistants

Operative details

The operative details section should provide an account of the procedure that was performed, to a level that would allow
accurate interpretation by another doctor. Operative details are valuable for continuity of care between the hospital and
community.
Operative details include\:
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Operative diagnosis (if relevant)
Antibiotic prophylaxis\: drug name, dose and duration
Venous thromboembolism (VTE) prophylaxis
Incision (e.g. type, size)
A step-by-step account of procedure performed\: this section will account for the majority of the operative record and should
be detailed enough that someone familiar with the procedure can understand what was performed
Immediate problems/complications from the procedure
Extra/unanticipated procedures performed and the indication
Tissues removed, added or altered
Prosthetic material used or implanted including relevant serial numbers (e.g. mechanical heart valve)
Closure technique\: type and size of suture material(s) and technique(s) used
Estimated blood loss\: calculated by checking suction bottles and weighing swabs
Swab, instrument, sharp count

Post-op care instructions

The post-op section is important as it directs the patient's care in recovery, on the ward, during their admission and potentially
beyond. This section will be much more speci
wish to include are\:
Immediate plan in recovery (e.g. oxygen saturation monitoring)
Antibiotic prophylaxis\: drug name, dose and duration
VTE prophylaxis
Blood tests or investigations required
Discharge plan\: conditions to be met before discharge
Follow-up plan\: who and when
Red
do if these symptoms occur)

Sign-o

The person documenting the operative record should sign o
Full name and signature
Grade
GMC number
Contact number (or emergency contact number – e.g. on-call team)

Example

Below is an example operation note for a simple ENT procedure, tonsillectomy. Whilst some aspects of this example will not
be relevant to operations from other specialities, the overall template will be similar.
Operation note
Patient name\: Miss Steph Pyogenes
Patient DOB\: 08/01/2006
Hospital No\: 1234567
NHS No\: 404-000-1234
Date\: 22/01/2021
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Time\: 15\:00
Location\: Theatre 2
Elective or emergency\: Elective
Indication\: Recurrent tonsilitis – 7 episodes in past 12 months
Procedure\: Bilateral bipolar tonsillectomy
Findings\: Bilateral grade 3 tonsils, signi
Surgeon\: Mr Alex North CT1
Assistant\: Mr Rakesh Mistry ST3
Anaesthetist\: Dr Jodie Gas
Procedure (step-by-step account)\:
General anaesthetic, supine, WHO checklist completed
No antibiotics, TED stockings worn
Boyle-Davis gag, Dra
Bipolar dissection (10W)
Bilateral palatine tonsils removed
Haemostasis ensured
Post-nasal space suctioned
Teeth, lips, tongue and TMJs checked and okay
Complications\: No problems, complications or unexpected steps
Specimens\:
Bilateral tonsils removed - not sent for histology
Closure technique\: [N o c l o s u r e r e q u i r e d i n t o n s i l l e c t o m y , b u t t e c h n i q u e a n d s u t u r e m a t e r i a l w o u l d b e d o c u m e n t e d h e r e ]
Blood loss\: Minimal
Equipment count\: Swab, instrument and sharps count correct
Post-operative plan\:
1. Immediate plan\: monitor oxygen saturations in recovery and inform surgeons if any bleeding
2. Antibiotics\: not required
3. VTE prophylaxis\: not required, can mobilise normally
4. Blood tests or investigations\: none required
5. Discharge plan\: home later today when eating and drinking
6. Follow-up plan\: virtual clinic appointment in 4 weeks in Ms Consultant’s clinic
7. Red
post-operatively
Sign o
Alexander North
CT1
GMC Number\: 123456
Contact on bleep 6111 or ENT on-call on 6163 if an emergency or out of hours

Reviewer

Rakesh Mistry
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ENT Registrar

References

1. Royal College of Surgeons of England. R e c o r d y o u r w o r k c l e a r l y , a c c u r a t e l y a n d l e gi b l y . Published in 2021. Available from\:
[LINK]
Source\: geekymedics.com
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