Brief Operative Note

(Use short labeled fields and bulleted lists; avoid long prose. For critical fields—Specimens, Drains/Catheters/Packing, Implants/Devices, Complications—always enter explicit content or "None"; never leave blank. If information is unknown at time of documentation, state "Unknown at time of note" with plan for reconciliation. Never infer procedures, diagnoses, specimens, implants, or complications.)

Procedure Date/Time: [Date and time]

Location: [Facility and room/suite]

Urgency: [elective / urgent / emergent]

Diagnoses

Preoperative Diagnosis: [Preoperative diagnosis]

Postoperative Diagnosis: [Postoperative diagnosis] (If unchanged, state "Same as preoperative")

Procedure(s) Performed

(List each procedure with exact name, laterality/site when applicable, and approach. Note any conversions. Use numbered list if multiple procedures.)

1. [Procedure name; laterality/site; approach (open/laparoscopic/robotic/endovascular/percutaneous); conversion if applicable]
2. [Additional procedure if applicable]

Operative Team

Primary Surgeon: [Name, credentials]

Assistant(s): [Name(s) and role(s), or "None"] (Include significant tasks only if explicitly described)

Anesthesia

Type: [general / regional / MAC / local / moderate sedation]

Key Findings

(Include pertinent negatives only when clinically meaningful)

• [Pertinent intraoperative finding]
• [Additional finding if applicable]

Technique Summary

(Brief description, 1–3 lines; not a full step-by-step operative report)

• [Key techniques and tissues removed or altered sufficient for continuity of care]
• [Counts: correct / discrepancy with management / "Unknown at time of note—pending final count"]

Blood Loss and Transfusion

EBL: [Estimated blood loss in mL] (Use "<X mL" or "0 mL" for negligible)

Blood Products: [Product(s) and amount(s), or "None"]

Specimens

(If none, enter "None")

• [Specimen: anatomic source; destination (pathology/culture/other)]
• [Additional specimen if applicable]

Drains / Catheters / Packing

(If none, enter "None")

• [Device type; size; anatomic location; secured status]

Implants / Devices

(If none, enter "None." If details pending, note "UDI/implant sticker to follow")

• [Implant/device type; anatomic location; manufacturer/model/lot or UDI if available]

Complications

(If none, enter "None." Do not document complications in other sections.)

• [Adverse event; intraoperative management; status at end of case]

Disposition and Condition

Disposition: [PACU / ICU / floor / other]

Condition: [stable / critical / guarded]

• [Immediate support status if relevant: intubated, vasopressors, etc.]
• [Immediate postoperative plan highlights not covered by standard order sets] (Optional; limit to 2–3 items)

Signature

[Primary surgeon electronic signature with date/time]

(If applicable: "Full operative report to follow.")