Soft Tissue Surgery Procedure Note

Patient Name: [Patient full name]    MRN: [Medical record number]

Date: [Procedure date]    Procedure Start/End Time: [Start time – End time]

Location: [Facility name; OR/procedure room number]

Primary Surgeon: [Surgeon name and credentials]    Assistants: [Assistant(s) name/role] (State "None" if unassisted)

Anesthesia Type: [general / MAC / regional / local / none]    Local Anesthetic: [Agent, concentration, total volume in mL] (Only include if local anesthesia used)

Laterality/Site: [Right / Left / Midline / Bilateral; anatomic site] (Include when applicable)

Preoperative Diagnosis

• [Diagnosis] (List in order of clinical importance; add lines if multiple diagnoses)

Postoperative Diagnosis

• [Diagnosis] (State "Same" if unchanged from preoperative diagnosis)

Procedure(s) Performed

• [Full procedure name with laterality and key qualifiers, size in cm] (Include descriptors such as depth, complexity, e.g., "debridement to fascia," "intermediate closure," "adjacent tissue transfer"; enumerate each site for multiple lesions)

Indication

[Concise rationale for procedure including clinical reasoning, relevant imaging/lab findings, and surgical intent] (1–3 sentences)

Informed Consent

[Consent statement confirming informed consent obtained, procedure-specific risks discussed, and alternatives considered] (1–2 sentences)

Findings

• [Intraoperative finding with size in cm and depth of involvement]
• [Tissue characteristics: abscess cavity, necrotic tissue, foreign material, cyst rupture, loculations]
• [Margins/orientation decisions for oncologic or uncertain lesions] (If applicable)
• [Neurovascular structures encountered or preserved] (If applicable)

Operative Technique

Positioning and Preparation: [Patient positioning, padding, skin prep solution, timeout and site marking confirmation]

Incision and Exposure: [Incision type, placement, length; dissection plane; key structures identified and protected]

Procedure: [Chronological description of core procedural steps] (For excisions: circumscription, dissection technique, capsule integrity, margin intent. For I&D: cultures obtained, loculations addressed, irrigation volume, packing strategy. For debridement: tissue planes debrided to, method, viable tissue endpoints. For flaps/grafts: design, donor site, inset method. For foreign body removal: object description, extraction method, neurovascular assessment. Include only the elements relevant to the procedure performed.)

Hemostasis: [Method(s) used: cautery, ligatures, topical agents]

Irrigation: [Solution type and volume] (Include if clinically relevant)

Closure: [Layered closure with suture material and size for each layer: deep, dermal, skin; staples/adhesive/steri-strips if used; final incision length; dressing type applied]

[Unexpected intraoperative decisions and rationale] (Include only if applicable)

Specimens

(Include this section only if specimens were obtained; omit entirely if none)

• [Specimen name, anatomic site/laterality, size in cm, orientation method if used, destination: pathology/microbiology] (List separately submitted margins individually)

Implants, Drains, and Materials

(Include this section only if implants, grafts, or drains were placed; omit entirely if none)

• [Implant/graft type, size, and location]
• [Drain type, size, number, location, exit site, securing method]

Estimated Blood Loss

[Numeric estimate in mL] (State "Minimal" if truly trivial)

Complications

[None / Description of complication and corrective action taken]

Counts

(Include only when surgical counts were performed; omit for minor procedures without counts)

• [Sponge/sharp/instrument counts: correct / discrepant with actions taken]
• [Packing intentionally left: type, location, plan for removal] (Only if applicable)

Disposition

[Patient condition: stable / guarded / critical] [Destination: PACU / floor / ICU / home] [Airway status if relevant]

Postoperative Plan

• Wound care: [Dressing type, when to remove/change, showering instructions, packing care if applicable]
• Activity: [Restrictions, elevation/compression instructions if relevant]
• Pain management: [Medication plan]
• Antibiotics: [None / Regimen, duration, and rationale]
• Follow-up: [Timing and purpose: wound check, suture removal, drain removal]
• Pathology/Culture follow-up: [Plan for reviewing and communicating results]
• Return precautions: [Fever, spreading erythema, increasing drainage, uncontrolled pain or bleeding]