Hand Surgery Operative Note

Patient Name: [Patient full name]

Date of Birth: [DOB]

MRN: [Medical record number]

Date of Surgery: [Date]

Start Time: [Time]

End Time: [Time]

Facility/Location: [Facility and operating room/location]

Primary Surgeon: [Surgeon name, credentials]

Assistant(s): [Assistant name(s), credentials / None]

Anesthesia Provider: [Provider name, credentials]

Anesthesia Type: [General / Regional (block type) / MAC / WALANT / Local]

Preoperative Diagnosis: [Diagnosis with laterality (left/right), digit (thumb/index/middle/ring/small), and anatomic level]

Postoperative Diagnosis: [Diagnosis with laterality, digit, and anatomic level] (If different from preoperative, clearly state changes.)

Procedure(s) Performed: [Procedure name(s) with laterality, digit, anatomic level, and approach (open / endoscopic / arthroscopic / percutaneous)]

Indications

[Indications for surgery including failed conservative treatments, duration of symptoms, or timing relative to trauma if applicable]

Preoperative Neurovascular Status

(Document baseline exam prior to block/anesthesia. If unable to perform, state "Unable to assess - [reason]" and reference prior documented exam if available.)

Sensory: [Findings by median/ulnar/radial distribution] [Pre-existing deficits: describe / None]

Motor: [Motor function by nerve distribution] [Pre-existing deficits: describe / None]

Perfusion: [Capillary refill, color, temperature]

Anesthesia and Positioning

Anesthesia: [Type and specifics] (For WALANT/local: include agent, concentration, volume, epinephrine use. For regional: include block type/location.)

Positioning: [Position], [laterality], [arm table setup]

Skin Prep and Drape: [Prep agent], [anatomic area prepped], [sterile draping]

Tourniquet

Tourniquet Used: [Yes / No]

(If Yes, include the following fields. If No, state "Tourniquet not used.")

Cuff Location: [Upper arm / Forearm / Digit]

Pressure: [mmHg]

Inflation Time: [Time]

Deflation Time: [Time]

Total Tourniquet Time: [Minutes]

Findings

• [Key pathology findings with structure-specific observations as relevant: nerve appearance/continuity, tendon quality/gliding, pulley status, bone/joint findings, soft tissue quality, contamination]
• [Additional findings]
• [Unexpected findings and any intraoperative plan changes]

(Add or remove bullets to reflect actual findings.)

Procedure Details

[Incision location and orientation with anatomic landmarks]

[Dissection approach and protection/identification of critical structures]

[Defining operative steps with confirmation of completeness]

[Hemostasis method and irrigation solution/volume if performed]

[Closure: layers, suture materials and sizes, skin closure method]

[Dressing and immobilization: dressing layers, splint/cast type, extremity position]

Tissues Removed/Altered

[Tissue removed/altered with anatomic source, laterality, and digit] [Specimen destination: pathology / microbiology / None]

(If no tissue/specimens, state: "No specimen.")

Implants

[Implant type, size, manufacturer, quantity, anatomic location]

(If no implants, state: "No implants.")

EBL, Drains, Complications

EBL: [mL]

Drains: [Type and location / None]

Complications: [Describe intraoperative complications and management / None]

Postoperative Condition

Disposition: [PACU / Same-day discharge / Floor / ICU]

Overall Condition: [Stable / Guarded / Critical]

Neurovascular Status: [Perfusion: capillary refill, color, temperature]; [Sensory/Motor: as assessable] (If limited by regional block, document what is assessable and state "Unable to fully assess - [reason]")

Postoperative Plan

• Immobilization: [Splint/cast/orthosis type], [position], [duration]
• Elevation/Edema Control: [Elevation instructions, compression, cold therapy]
• Wound Care: [Dressing change timing], [bathing instructions], [suture removal timing]
• Activity Restrictions: [Lifting/grip restrictions], [work/ADL limitations], [duration]
• Range of Motion: [Immediate / Delayed], [joints included], [active / passive], [frequency]
• Hand Therapy: [Yes / No], [protocol name if applicable], [timing to start]
• Medications: [Analgesia], [antibiotics if indicated]
• Return Precautions: [Fever, increasing pain, progressive numbness/weakness beyond expected block duration, color change/coolness, excessive swelling/bleeding]
• Follow-up: [Timing], [service/clinic], [imaging if needed]

(Keep laterality and digit explicit throughout. For any required element that cannot be assessed, document "Unable to assess - [reason]" rather than leaving blank.)