Operative Report (Craniotomy/Craniectomy for Hematoma Evacuation)

Patient: [Patient name/identifiers per local policy]

MRN: [Medical record number]

Date of Birth: [DOB]

Date of Procedure: [Procedure date]

Time: [Start time] – [Finish time]

Case Status: [emergent / urgent / scheduled]

Location: [OR/Facility/Room]

Surgeon: [Primary surgeon name, credentials]

Assistant(s): [Assistant names, credentials]

Anesthesiologist: [Name, credentials]

Pre-operative Diagnosis: [Left / Right / Bilateral] [EDH / SDH / ICH], [anatomical location]

Post-operative Diagnosis: [Left / Right / Bilateral] [EDH / SDH / ICH], [anatomical location]

Procedure(s) Performed:

• [Standardized procedure name with laterality] (If procedure changed intraoperatively, list both intended and final procedures)

Indications and Consent

[Clinical indication and urgency] (Include neurological deterioration, herniation signs, or key imaging findings such as hematoma size, midline shift, or cistern effacement)

Preoperative Neurological Status: GCS [score] (E[#]V[#]M[#]), pupils [size/reactivity], [focal deficits or "nonfocal"], [exam limitations if sedated/paralyzed]

Coagulation/Anticoagulants: [Anticoagulant/antiplatelet use or "None"], [coagulopathy status], [reversal measures and timing if given]

Consent: [Consent obtained from patient / family member / healthcare proxy with risks, benefits, and alternatives discussed / Emergency exception invoked due to life-threatening condition and inability to obtain consent] (Do not infer; state explicitly if unknown)

Preoperative Preparation

Time-out: Completed, verifying patient, procedure, and laterality

Antibiotic Prophylaxis: [Agent and dose / Per anesthesia record]

Positioning and Fixation: [Supine / Lateral / Prone], head fixed in [Mayfield pins / Horseshoe headrest], [pressure points padded]

Skin Prep and Incision Planning: [Prep agent], [incision type and landmarks], [trauma lacerations or prior scars affecting approach if applicable]

Adjuncts: [Neuronavigation / Intraoperative ultrasound / None]

Intraoperative Findings

• Hematoma: [Left / Right] [EDH / SDH / ICH], [location], [acute / subacute / chronic / mixed], [approximate volume or thickness]
• Brain/Dura: Dura [tense / relaxed], brain [swollen / relaxed after evacuation], [herniation signs if present]
• Bleeding Source: [Identified source and control method / No discrete source identified]
• Associated Injuries: [Skull fracture / Dural tear / Cortical contusions / Traumatic SAH / Contamination / None identified] (Document only structures directly visualized)

Operative Description

[Detailed stepwise narrative of the operation in past tense] (Include: positioning and incision; scalp flap and soft tissue dissection; burr hole placement and bone flap creation or craniectomy extent; hematoma evacuation technique; hemostatic maneuvers. For decompressive craniectomy, document decision-making: brain status after evacuation, ICP or swelling cues prompting bone flap removal. If converted from craniotomy to craniectomy, state when and why.)

Bone Flap Management

• Bone Flap Disposition: [Replaced and secured / Left off (decompressive craniectomy) / Discarded / Not confirmed at time of dictation—to be updated] (Do not infer; must be explicitly stated)
• If Replaced: [Fixation method and number of fixation points]
• If Left Off: [Storage location and method per facility protocol / Discarded due to contamination or fragmentation]; craniectomy margins [describe adequacy using anatomical landmarks]
• Dural Management: [Primary closure / Duraplasty with graft type / Onlay / Dura left open], [watertight / not watertight]

Drains and Monitors

• [Device type]: [Left / Right] [location], [settings], secured with [method], initial [ICP reading / output] (Include each device placed)
• [None—no drains or monitors placed] (State explicitly if none)

Hemostasis and Blood Products

Estimated Blood Loss: [mL]

Fluids/Blood Products: [Summary of significant transfusion events / Per anesthesia record]

Hemostatic Agents: [Agents left in situ / None]

Intraoperative Coagulopathy Management: [Interventions given / None / Per anesthesia record]

Specimens and Implants

Specimens: [Specimen type sent to pathology/microbiology / No specimens sent]

Implants: [Cranial fixation hardware, dural substitute with manufacturer/size / Per implant log / No implants]

Counts and Complications

Counts: [Sponge, needle, and instrument counts correct / Discrepancy noted—describe and resolution]

Complications: [Description, clinical impact, and corrective action / No intraoperative complications] (Do not infer; must be explicitly stated)

Closure

[Dural closure technique], [bone flap fixation if replaced], [soft tissue closure by layer], [skin closure method], [dressing applied]

Postoperative Plan

Disposition: [ICU / PACU], [intubated / extubated], hemodynamically [stable / requiring support]

Neurological Status at Case End: Pupils [findings], [best available exam or "sedated/paralyzed—exam limited"]

Imaging: CT head [timing]; repeat urgently for [neurological decline / ICP crisis / other triggers]

ICP Management: [Target ICP threshold, CPP goal, escalation triggers / No ICP monitor—clinical monitoring]

Neuro Checks: [Frequency] for [duration]

Ventilation: [Sedation goals], avoid coughing/bucking, target normocapnia, avoid hypotension and hypoxia

Seizure Prophylaxis: [Agent, dose, route] for [planned duration]

DVT Prophylaxis: Mechanical prophylaxis now; chemoprophylaxis [timing contingent on stability and repeat imaging]

Antibiotics: [Agent and duration / Per anesthesia record]; [special considerations for open fracture/contamination if applicable]

Drain Management: [Each drain: suction vs gravity, expected output, removal criteria]

Craniectomy Precautions: [Helmet when out of bed, positioning considerations, cranioplasty follow-up planning] (Include if bone flap left off)

Attestation

[Surgeon electronic signature, date/time]

[Attending participation statement per local compliance requirements] (Include if teaching case)