Operative Report (Orthopedic Surgery)

Patient: [Patient name], [MRN], [DOB]

Date of Surgery: [Date]; Start: [Incision start time]; Stop: [Incision stop time]

Facility/OR: [Facility name]; [OR number]

Case Classification: [elective / urgent / emergent]

Primary Surgeon: [Name, credentials]

Assistant(s): [Assistant name, role, and significant tasks performed] (List each assistant with name, role, and key tasks such as opening, closing, graft harvest, or implant placement. Use separate entries for multiple assistants.)

Anesthesia: [Anesthesia type] (If a regional block was used and is relevant to the postoperative neuro exam, specify block type and limb.)

Diagnoses

Preoperative Diagnosis: [Diagnosis with laterality/level]

Postoperative Diagnosis: [Diagnosis with laterality/level] (If postoperative diagnosis differs from preoperative, reconcile with intraoperative findings.)

Procedure(s) Performed

(List all procedures in chronological order. Each procedure must include explicit laterality and anatomic site/level. Do not infer laterality or level.)

• [Laterality] [Anatomic site/level] — [Procedure name]
• [Additional procedures as performed]

Indications

[Surgical indication, key imaging findings driving the decision, and relevant comorbidities affecting approach or risk. Include statement of informed consent.] (Keep focused on surgical rationale. Do not reproduce full H&P.)

Intraoperative Findings

[Findings affecting diagnosis or plan: fracture pattern, cartilage/meniscus/ligament status, soft tissue condition, bone quality, infection findings, neurovascular status] (If no unexpected findings, state "Findings were as expected.")

Operative Setup

Position: [supine / prone / lateral decubitus / beach chair]; [Positioning details, padding, supports, traction]

Tourniquet: [not used / Location, pressure in mmHg, total time or inflation/deflation times] (Always explicitly state "not used" if no tourniquet.)

Antibiotics/Adjuncts: [Prophylaxis agent and timing; TXA if used] (For infection cases, note whether antibiotics were held until cultures obtained.)

Operative Technique

Approach

[Incision location and length; surgical approach; interval used; critical structures identified and protected]

Exposure

[Dissection; releases or capsulotomy; soft tissue handling]

Key Steps

[Core procedural actions in sequence] (Document what was actually performed. Avoid generic statements such as "standard technique.")

Reduction/Fixation

[Reduction method; provisional fixation; definitive fixation details including implant constructs] (Do not infer implant details from procedure name.)

Verification

[Reduction confirmation; stability testing; ROM; alignment and leg length checks; intraoperative measurements]

Implants and Hardware

[Construct summary] (Brief description of overall fixation or arthroplasty construct.)

• Implant: [Device type] — [Manufacturer], [Model/System], [Size/Dimensions]; Location: [Anatomic site/side/level]; Identifiers: [UDI, Catalog #, Lot #, Serial #] (If identifiers are captured elsewhere in the record, indicate where.)
• [Additional implants as applicable]

Cement: [none / Type, antibiotic-impregnated: yes/no]

Bone Graft/Biologics: [none / Type, amount, location]

Hardware Removed: [none / Description, quantity, disposition: pathology/culture/discarded]

(If no implants remain, state "Implants: none.")

Imaging

Fluoroscopy: [not used / Views obtained, verification achieved, images archived] (Include time or dose metrics per local policy.)

Intraoperative CT/Navigation/Robotics: [none / Modality and purpose]

Neuromonitoring: [none / Modality and any significant alerts or events]

Specimens and Cultures

[none / Specimen type, source with laterality/level, destination, culture types if applicable]

EBL and Drains

EBL: [Numeric mL / minimal] (Note transfusion or cell saver if used.)

Drains: [none / Type, location, number]

Closure and Dressing

[Irrigation; hemostasis; closure by layer and method; local anesthetic infiltration if performed; dressing type; immobilization applied with joint position if relevant]

Counts

[Sponge, needle, and instrument counts were correct.] (If a discrepancy occurred, document actions taken and resolution.)

Complications

[none / Description of event, consequence, repair or mitigation, and implications for postoperative monitoring] (Do not leave blank. Explicitly state "none" if no complications.)

Disposition

Condition: [Patient condition at end of procedure]

Destination: [PACU / ICU / ward]

Neurovascular Status: [Brief postoperative exam summary] (Include especially after tourniquet use, reduction, or compartment-risk injury.)

Postoperative Plan

• Weight-Bearing/Activity: [WBAT / PWB / TTWB / NWB; ROM restrictions; brace/splint instructions]
• PT/OT: [Initiation timing; gait training; ROM protocol]
• DVT Prophylaxis: [Agent, dose, duration]
• Antibiotics: [Prophylaxis duration or infection-directed regimen]
• Pain Management: [Regional block expectations; multimodal plan]
• Wound Care: [Dressing changes; showering; suture/staple removal timing]
• Imaging: [Postoperative radiograph timing if indicated]
• Follow-up: [Clinic timing; warning signs to report]

(Do not infer postoperative restrictions—include only explicitly documented instructions.)

Surgeon Attestation

Surgeon Signature: [Name, credentials] — [Date, time]

Dictation: [Dictation date/time if applicable]

Brief Operative Note

(Optional. Use when full operative report will be completed later but immediate documentation is needed before patient transfer.)

Surgeon: [Name]

Assistant(s): [Names and roles]

Procedure(s) Performed: [Procedures with explicit laterality and anatomic site/level]

Postoperative Diagnosis: [Diagnosis]

Key Findings: [Concise intraoperative findings]

EBL: [Numeric mL / minimal]

Specimens: [none / List]

Complications: [none / Description]

Implants: [none / Brief descriptor of construct]

Disposition: [PACU / ICU / ward]

Immediate Plan: [Weight-bearing status; antibiotics; DVT prophylaxis; immobilization]