Operative Report (Burr Hole Drainage of Chronic Subdural Hematoma)

Patient name: [Patient name]

MRN: [Medical record number]

DOB: [Date of birth]

Date of surgery: [Date of surgery]

Start time: [Start time] (Include only if captured)

Stop time: [Stop time] (Include only if captured)

Facility/OR: [Facility name / OR number]

Primary surgeon: [Surgeon of record] (Required)

Assistant(s): [Assistant(s)]

Anesthesia team: [Anesthesiologist and/or CRNA(s)]

Anesthesia type: [general / monitored anesthesia care / local with sedation]

Case urgency: [elective / urgent / emergent]

Laterality: [Right / Left / Bilateral] (Required; never infer; use "REQUIRED—NOT DOCUMENTED" if missing)

Diagnoses and Procedures

Preoperative Diagnosis: [Chronic subdural hematoma with laterality and relevant modifiers] (Include laterality and modifiers that drive management such as anticoagulant use, recurrence, septations, or midline shift)

Postoperative Diagnosis: [Updated diagnosis reflecting intraoperative findings] (Required; update if unexpected acute component, bilateral disease, or infection suspected)

Procedures Performed:

• [Burr-hole drainage of chronic subdural hematoma, laterality]
• [Placement of subdural drain, laterality] (Include only if performed)
• [Irrigation, laterality] (Include only if performed)
• [Additional procedures with laterality] (Include only if performed)

Indications

[Indications narrative] (4–8 sentences summarizing: symptoms and neurologic deficits prompting intervention; imaging features including side, size, shift, and septations if relevant; failure of conservative management if applicable; rationale for burr-hole technique; and high-risk context such as anticoagulation, frailty, or prior recurrence)

Consent, Site Verification, and Antibiotics

Consent: [Informed consent obtained] (Note if from surrogate or under emergent exception)

Site verification: [Site marking and time-out completed with correct patient, procedure, and laterality confirmed]

Antibiotics: [Prophylactic antibiotics administered / not administered] (If given, specify agent and timing)

Anesthesia and Positioning

• [Anesthesia type]
• [Patient position and head elevation]
• [Head fixation method]
• [Pressure point and eye protection measures] (Include if applicable)

Intraoperative Findings

• Side confirmed: [Right / Left / Bilateral] (Never infer)
• Hematoma character: [Fluid color, consistency, membranes, loculations as observed]
• Pressure upon opening: [Under pressure / low pressure] (Include only if observed)
• Brain re-expansion: [Degree of re-expansion and pulsatility observed]
• Active bleeding: [Present with source / absent]
• Subdural membrane status: [Outer and inner membrane features as observed]
• Unexpected findings: [Acute blood, infection, CSF leak, or other findings] (Include only if present)

(For bilateral cases, document findings separately for each side)

Operative Technique

(For bilateral cases, use separate Right-sided and Left-sided subsections below. For unilateral cases, use a single subsection labeled with the operative side.)

[Right / Left]-sided procedure

Incision and Burr Hole: [Skin incision location relative to anatomic landmarks; number and location of burr holes; method of creation and bone-edge hemostasis]

Dural Opening and Evacuation: [Method of dural opening; whether outer membrane was opened; technique of evacuation including passive egress, suction, or manual expression]

Irrigation: [Irrigant type, technique, and stopping criteria] (If not performed, state "Irrigation was not performed")

Hemostasis and Closure: [Hemostasis methods; burr-hole cover if used; closure layers; dressing applied]

[Right / Left]-sided procedure

(Include this subsection only for bilateral cases)

Incision and Burr Hole: [Skin incision location relative to anatomic landmarks; number and location of burr holes; method of creation and bone-edge hemostasis]

Dural Opening and Evacuation: [Method of dural opening; whether outer membrane was opened; technique of evacuation including passive egress, suction, or manual expression]

Irrigation: [Irrigant type, technique, and stopping criteria] (If not performed, state "Irrigation was not performed")

Hemostasis and Closure: [Hemostasis methods; burr-hole cover if used; closure layers; dressing applied]

Drain Placement

(Required section. If no drain placed, state "No drain placed" with rationale and omit bullet list below.)

• Drain type and size: [Subdural / subperiosteal / subgaleal; catheter size]
• Laterality: [Right / Left / Bilateral]
• Path and position: [Tunnel direction, depth, target location]
• External system: [Gravity / suction with setting]
• Securing: [Method used; closed system confirmed]

Specimens and Implants

(Omit this section entirely if not applicable)

• Specimens: [Specimens sent with destination]
• Implants: [Burr-hole covers, hemostatic agents, or other implants with identifying details]

Estimated Blood Loss and Complications

EBL: [Numeric value / minimal]

Complications: [None / Description of complication, immediate management, procedural impact, and anticipated postoperative consequences] (Document clearly; do not minimize)

Disposition

• Airway: [Extubated / remained intubated]
• Destination: [PACU / ICU / step-down]
• Neurologic status: [At baseline / improved / worsened]
• Hemodynamic status: [Stable / unstable]
• Drain status on transfer: [Clamped / open; gravity / suction; side-specific if bilateral]

Postoperative Plan

Drain Management: (Include only if drain placed)

• Setting: [Gravity / suction with level reference]
• Monitoring: [Output frequency and character to monitor]
• Escalation criteria: [Thresholds for high output, sanguineous drainage, or neurologic decline]
• Removal plan: [Planned timing or criteria for removal]
• Activity restrictions: [Head-of-bed and mobilization restrictions]

Imaging Plan: [Whether routine CT planned; timing relative to drain status; triggers for additional imaging]

Anticoagulation/Antiplatelet Plan: (Include if applicable; otherwise state "Not applicable")

• Held/reversed: [Agents held preoperatively and reversal if performed]
• VTE prophylaxis: [Mechanical / chemical with start timing]
• Resumption plan: [Drug, timing, contingencies, and specialty consultation if involved]

Authentication

[Surgeon signature] — [Date and time signed]