Cataract Surgery Operative Note (Phacoemulsification/IOL)

(Use past tense and objective language. Laterality must be explicit wherever specified. If both eyes were operated on the same day, generate two separate operative notes.)

Patient: [Full name] | [DOB] | [MRN]

Date of Surgery: [Date]

Eye: [Right (OD) / Left (OS)] (If laterality cannot be determined, flag as incomplete.)

Procedure: Phacoemulsification cataract extraction with posterior chamber intraocular lens implantation, [Right (OD) / Left (OS)] eye [Adjunct procedures if performed: anterior vitrectomy, capsular tension ring, pupillary expansion device, synechiolysis, wound suturing]

Preoperative Diagnosis: [Diagnosis with laterality]

Postoperative Diagnosis: [Diagnosis with laterality] (Should match preoperative unless new diagnosis identified intraoperatively.)

Surgeon: [Surgeon name, credentials]

Assistant(s): [Assistant name(s), credentials] (Omit line if none.)

Anesthesia: [topical/MAC / retrobulbar / peribulbar / sub-Tenon's / general]

Indication and Verification

[Functional/clinical indication for surgery] [Relevant ocular risk factors influencing surgical planning, if any] Informed consent was verified. A time-out was performed confirming correct patient, procedure, and [Right (OD) / Left (OS)] eye.

Anesthesia and Medications

[Anesthesia type and route; for regional blocks include agent(s) if locally required] [Intracameral medications: lidocaine, antibiotics, miotics as applicable] [Viscoelastic type(s)] [Subconjunctival injections if given]

Intraoperative Findings

[Findings that influenced technique or create follow-up risk: cataract density/type, pupil behavior, zonular status, capsule condition, corneal clarity at end of case] (If all findings unremarkable, state "No abnormal intraoperative findings." Include only clinically relevant observations.)

Operative Technique

(Chronologic narrative in past tense describing the procedure actually performed. If a complication occurred, document it at the relevant step: what occurred, management, and consequence for postoperative care.)

Setup: [Patient positioning, eye prepped and draped in sterile fashion, lid speculum placed]

Incisions: [Paracentesis location] [Main wound type, location, and size] [Intracameral anesthetic if given] [Viscoelastic instilled]

Capsulorhexis: [Continuous curvilinear capsulorhexis: manual / femtosecond-assisted] [Capsule staining with trypan blue if used]

Hydrodissection/Hydrodelineation: [Performed / Not performed] [Nuclear rotation confirmed if applicable]

Phacoemulsification: [Technique: divide-and-conquer / stop-and-chop / phaco chop / other] [Modifications for dense cataract if applicable]

Cortical Removal: [Irrigation/aspiration performed] [Posterior capsule integrity] [Capsular polishing if performed]

IOL Implantation: [IOL inserted and unfolded] [Final position: in-the-bag / sulcus] [Lens centered] [For toric: final axis alignment in degrees]

Closure: [Viscoelastic removed] [Wounds hydrated and confirmed watertight] [Sutures if placed: type and location] [Final medications] [Shield or patch placed]

Implant

IOL Manufacturer: [Manufacturer]

IOL Model: [Model]

IOL Power: [Diopters]

Cylinder/Axis: [Cylinder] at [Axis in degrees] (Include for toric lenses only.)

Serial/Lot/UDI: [Identifier] (If unavailable at dictation, note "see implant log" and reconcile before signing.)

Final Location: [in-the-bag / sulcus / anterior chamber]

Additional Devices: [Capsular tension ring or other device with model/lot if available] (Omit if none.)

Complications

[None / List each complication: posterior capsule rupture, zonular dialysis, vitreous loss, Descemet detachment, etc.] (Required field. Must be consistent with operative narrative.)

Disposition

[Patient condition at end of case] [Destination: recovery / discharge] [Eye shield or patch status]

Postoperative Plan

[Follow-up timing] [Topical regimen or reference to standard discharge instructions] [Special precautions if complications occurred: IOP monitoring, retina follow-up, activity restrictions]

Signature: [Surgeon name, credentials] | [Date] | [Time]