Operative Note

Patient Name: [Patient name]

MRN: [Medical record number]

Date of Birth: [Date of birth]

Procedure Date: [Date of surgery]

Start Time: [Start time]

End Time: [End time]

Facility/OR: [Facility name and OR number]

Case Type: [elective / urgent / emergent], [inpatient / outpatient]

Primary Surgeon: [Primary surgeon name and credentials]

Assistant(s): [Assistant name(s) and credentials]

Anesthesia Type: [general / regional / MAC / local / combined]

Procedure(s) Performed: [Exact procedure title(s) with laterality/level/site]

Preoperative Diagnosis: [Preoperative diagnosis with laterality/level/site]

Postoperative Diagnosis: [Postoperative diagnosis with laterality/level/site] (State "Same as preoperative" only if explicitly unchanged)

Indications & Consent

[Rationale linking diagnosis, symptoms, or imaging to the decision for surgery, including failed nonoperative care when relevant. Statement that informed consent was obtained, or documentation of emergency exception if applicable.] (2–5 sentences in past tense. Do not reproduce the full consent discussion.)

Operative Team & Roles

• [Team member name and role] — [Specific surgical tasks performed]

(List each surgeon, assistant, and trainee who performed significant surgical tasks. Explicitly attribute tasks performed by trainees or non-primary practitioners per CMS guidance for teaching settings.)

Pre-Procedure Verification & Setup

• [Time-out completed with verification of patient, procedure, laterality/site, and required equipment]
• [Patient position and supports/precautions]
• [Antibiotic prophylaxis: agent, dose, timing relative to incision] (If not given, state rationale)
• [VTE prophylaxis: mechanical and/or pharmacologic]
• [Special equipment/adjuncts: fluoroscopy / navigation / robot / tourniquet / neuromonitoring / cell saver] (Include only items used)

Operative Findings

[Key findings that corroborate the diagnosis and influenced intraoperative decisions. Pertinent negatives when clinically meaningful. If findings changed the planned procedure, document decision and rationale.]

Procedure Details

Approach: [Incisions/ports, entry into operative field, side/level/site confirmation, exposure achieved. If conversion occurred, state when and why.]

Key operative steps: [Chronological description of dissection planes, identification of critical anatomy, protection of adjacent structures, resection/reconstruction techniques, use of imaging guidance or energy devices.]

Hemostasis: [Methods used and confirmation of hemostasis.]

Closure: [Fascial closure details, layered closure of tissues, skin closure method, dressings and immobilization.]

Intraoperative Data

• Estimated Blood Loss: [Volume] (Numeric value preferred)
• IV Fluids: [Type and volume]
• Blood Products: [Products and units] (Omit if none)
• Tourniquet Time: [Duration and pressure] (If used)
• Urine Output: [Volume] (If monitored)

Counts

[Statement documenting sponge, needle, and instrument counts and final status.] (If discrepancy occurred, document discrepancy, reconciliation steps including search/wound exploration/imaging, and final resolution. If item intentionally retained, specify item, location, and rationale. This section must not be ambiguous.)

Specimens

1. [Specimen label] — [Source/site with laterality; orientation markers if placed; destination]

(Include only if specimens were removed. If none, omit section or state "No specimens" per local convention.)

Implants

1. [Device name/type] — [Manufacturer; model/catalog number; lot/serial number; implant location with laterality]

(Include only if implants, prostheses, or grafts were placed.)

Drains & Lines

1. [Type and size] — [Location with laterality; method of securement; initial settings]

(Include only if drains or temporary devices were placed.)

Complications

Complications: [None / Description of complication, management, patient response, consultants involved, and status at end of case]

(This section is required and must always contain an explicit statement.)

Disposition

• Condition: [Patient condition at end of case: stable/unstable; airway status; hemodynamic support if any]
• Destination: [PACU / ICU / ward / home]
• Handoff: [Critical information relayed to receiving team] (Include drains, lines, special monitoring needs, pending tests)

Postoperative Plan

• Diet: [NPO / clear liquids / advance as tolerated / other restrictions]
• Activity: [Weight-bearing status, mobility restrictions]
• Pain control: [Regional block status, multimodal regimen]
• Antibiotics: [Agent, indication, duration]
• VTE prophylaxis: [Type, dose, start time]
• Wound/drain care: [Dressing changes, drain care, removal criteria]
• Labs/imaging: [Tests ordered with timing]
• Follow-up: [Service, clinic timing, suture/staple removal]
• Contingencies: [Parameters for contacting surgeon, return-to-OR thresholds]

Signature

[Electronic signature of surgeon with date and time]

(If full operative note completed later than immediately post-procedure, reference the brief operative note entered at time of surgery per local policy.)