Operative Note (Foot/Ankle Surgery)

Patient: [Full name], MRN: [Medical record number], DOB: [Date of birth]

Date of Surgery: [Date]

Procedure Start Time: [Start time]

Procedure End Time: [End time]

Facility/OR: [Facility and operating room]

Laterality: [Left / Right / Bilateral]

Preoperative Diagnosis

• [Diagnosis with laterality and anatomic specificity]
• [Additional diagnosis] (Include additional items as needed.)

Postoperative Diagnosis

• [Diagnosis with laterality and anatomic specificity]
• [Updated or additional diagnosis based on intraoperative findings] (Only include if applicable.)

(May state "Same as preoperative" only if truly unchanged.)

Procedure(s) Performed

• [Procedure name with laterality and anatomic site/level] (List in order performed.)
• [Additional procedure] (Include additional items as needed.)
• [Planned procedure not performed]: [Reason] (Only include if applicable.)

Indications

[Brief indications summary] (2–4 sentences covering: symptom/diagnosis summary; failure of nonoperative care when applicable; procedure goals; confirmation of informed consent and laterality verification.)

Surgical Team

Primary Surgeon: [Name, credentials]

Assistant(s): [Name(s) and role(s) / None]

Anesthesia

Anesthesia Type: [General / Regional / MAC / Local]

Regional Block: [Type and approach / Per anesthesia]

Surgeon-Administered Local: [Agent, concentration, volume, injection sites] (Include when clinically relevant.)

Tourniquet

Tourniquet Used: [Yes / No]

(If no tourniquet used, state "No tourniquet used" and omit fields below.)

• Location: [Thigh / Calf / Ankle], [Left / Right]
• Pressure: [mmHg]
• Inflation Time: [Time]
• Deflation Time: [Time]
• Total Duration: [Minutes]
• Exsanguination Method: [Elevation / Esmarch / Other]

Operative Findings

[Key intraoperative findings] (Brief paragraph or bullet list describing: cartilage status, tendon/ligament integrity, bone quality, deformity characteristics, infection/necrosis if present. Include at least one finding statement even if "Findings consistent with preoperative imaging.")

Description of Procedure

(Chronological narrative from incision to closure. Use short paragraphs or numbered steps. For multi-procedure cases, use h3 subheadings by procedure.)

[Procedure name with laterality and site/level]

1. [Patient positioning, prepping, and draping]
2. [Incision/approach: incision type, portals if arthroscopic, dissection plane, key landmarks]
3. [Exposure: neurovascular and tendon structures identified and protected]
4. [Key operative steps: osteotomies, tendon repair, debridement, tissue excision, grafts/biologics]
5. [Fixation technique: implant type and placement, alignment checks]
6. [Reduction quality and confirmation: fluoroscopy views, stress testing, alignment assessment]
7. [Tourniquet deflation and hemostasis] (Only if tourniquet used.)
8. [Irrigation: type and volume] (Only if infection or contamination addressed.)
9. [Closure: layers, suture materials and sizes, skin closure technique]
10. [Dressing and immobilization: dressing type, splint/cast/boot, final position]

[Additional procedure name with laterality and site/level]

(Include only if additional procedures performed. Repeat structured steps as appropriate.)

Implants/Hardware

• [Implant name/type], [Manufacturer], [Size/length/diameter], [Quantity], [Anatomic location], [Lot/Serial/UDI]
• [Temporary hardware left in place and intended removal plan] (Only if applicable.)

(If no implants, state "None.")

Specimens/Cultures

• Specimens: [Type], [Source site with laterality], [Destination]
• Cultures: [Aerobic / Anaerobic / Fungal / AFB], [Source site]

(If none sent, state "None.")

Estimated Blood Loss

EBL: [mL / Minimal]

Drains: [Type, location, management instructions / None]

Complications

[Complication description, management performed, clinical impact] (If none, state "None apparent.")

Disposition

Condition: [Stable / Guarded]

Transferred to: [PACU / Ward / Discharged home]

Postoperative Plan

• Immobilization: [Splint/cast/boot type]; keep clean and dry; [Elevation instructions]; [Dressing change timing]
• Weight-Bearing Status: [NWB / TTWB / PWB / WBAT]; [Assistive device]; [Duration]
• Pain Management: [Multimodal regimen]; [Nerve block expectations]; [Ice/elevation instructions]
• Antibiotics: [Postoperative antibiotic plan / None planned]
• VTE Prophylaxis: [Mechanical / Pharmacologic]; [Agent and duration if applicable]
• Imaging: [Postoperative X-ray timing and views] (Only if needed.)
• Follow-up: [Clinic visit timeframe]; [Suture removal timing]; [Pin removal plan if applicable]
• Return Precautions: fever, increasing pain/swelling, wound drainage, numbness beyond expected block duration, splint tightness

(Meta: Do not infer laterality, implant placement, complications, or specimen status—these must be explicitly stated or documented as absent. If a required element cannot be determined, use a placeholder such as [Information needed] rather than omitting. For items truly not applicable to the case, omit the section rather than populating with "N/A.")