Spay/Neuter Surgery Note

Date of Service: [Date and time of anesthesia and surgery]
Facility/Site: [Clinic name or mobile unit identifier]
Case/Record ID: [Encounter or medical record number]

Patient: [Name or shelter ID], [Species], [Breed], [Sex: intact male / intact female], [Age or age class], [Color/markings], [Weight in kg] ([Date obtained])
Microchip: [Number / placed today / none]
Tattoo/Ear Tip: [Pre-existing / performed today / none]

Client/Organization: [Owner or shelter/rescue name], [Contact information], [Caretaker if community cat]

Procedure Summary

• Procedure performed: [Canine OHE / Canine OVE / Canine castration / Feline OHE / Feline OVE / Feline castration / Cryptorchid castration]
• Anesthesia type: [Injectable / Inhalant / Balanced], Airway: [ETT / mask / none]
• Key intraoperative findings: [Normal / Abnormalities described]
• Complications: [None / specify]
• Disposition: [Same-day discharge / Held for extended recovery / Transferred] [Destination and reason if applicable]

Pre-Anesthetic Assessment

• Fasting status: [Yes / No / Unknown]
• Relevant history: [Prior anesthesia issues / Current medications / Illness signs / None reported]
• Physical exam:
  • General appearance: [Normal / Abnormal: description]
  • Hydration/Perfusion: [Normal / Abnormal: description]
  • Cardiac auscultation: [Normal / Abnormal: description]
  • Respiratory auscultation: [Normal / Abnormal: description]
  • Mucous membranes/CRT: [Normal / Abnormal: description]
  • Temperature: [Value and unit / Not obtained]
• Risk category: [ASA I / ASA II / ASA III / ASA IV / ASA V / Clinic-specific tier] — [Brief rationale]
• Precautions/flags: [None / Brachycephalic / Pediatric / Geriatric / Pregnant / Debilitated / Cardiac murmur / Other]
• Point-of-care labs: [Test, value, interpretation] (Omit section entirely if not performed)

Anesthesia Record

Anesthesia Plan: [Premedication goals], [Induction agent], [Maintenance method], [Airway management and rationale if not intubated], [Analgesia strategy], [Temperature management measures]

Drug Administration Log (Each drug requires patient-specific dose, route, and time; do not reference protocols without individual entries)

• [Medication (generic)] — [Dose mg/kg], [Total mg], [Route], [Time], [Notes or adverse reaction if any]
• (Add entries for each premedication, induction agent, maintenance agent, analgesic, local block, reversal, or rescue drug)

Anesthesia Timeline

• Sedation: [HH:MM]
• Induction: [HH:MM]
• Intubation: [HH:MM / Not intubated]
• Surgery start: [HH:MM]
• Surgery end: [HH:MM]
• Extubation: [HH:MM / Not intubated]
• Recovery/discharge: [HH:MM]

Monitoring Record (Record HR and RR every 5–10 minutes; include SpO2, EtCO2, BP if monitored; temperature at least once during anesthesia and recovery. Use "not recorded" for missing values rather than leaving blank.)

• [Time]: HR [bpm], RR [brpm], SpO2 [%], EtCO2 [mmHg], BP [mmHg], Temp [°C/°F], Depth [light / adequate / deep], [Adjustments or comments]
• (Add line for each monitoring interval)

IV Access and Fluids: [IV catheter: Yes (site) / No] — [Fluids: type, rate mL/kg/hr, total volume mL / Not administered]

Anesthetic Events: [No anesthetic complications] or [Event: time, description, intervention, outcome]

Surgical Time-Out

• Patient identity confirmed: [Method: ID band / microchip / chart / verbal]
• Correct procedure confirmed: [Yes / No — corrected prior to incision]
• Sex verified: [Male / Female] by [Physical exam / Records]
• Allergies/sensitivities: [None known / List]
• Special conditions flagged: [None / Pregnancy suspected / Pyometra suspected / Pediatric / Brachycephalic / Other]
• Prophylactic antibiotic: [Not indicated / Yes: drug, dose, route, time / No: reason]
• Sterility breaks: [None / Description and corrective action]

Operative Report

Surgeon: [Name]

(Include only the applicable pathway below; omit the other)

Spay (OHE or OVE)

• Procedure: [Ovariohysterectomy / Ovariectomy]
• Approach: [Ventral midline / Flank], Incision: [Standard / Extended]
• Ovarian pedicle ligation: [Method], [Suture material and size]
• Uterine body ligation: [Method], [Suture material and size]
• Hemostasis confirmed: [Yes / No]
• Intraoperative findings (Require explicit documentation; if not mentioned, prompt for confirmation):
  • Pregnancy: [No / Yes: stage estimate]
  • Pyometra: [No / Yes: description]
  • Other abnormalities: [None / Cysts / Masses / Adhesions / Hernia / Other: description]
• Closure:
  • Linea alba: [Suture material and size]
  • Subcutaneous: [Suture material and size / Not closed]
  • Skin: [Intradermal / Skin sutures / Staples / Tissue adhesive], [Material if applicable]

Neuter (Castration)

• Approach: [Pre-scrotal / Scrotal], Technique: [Open / Closed]
• Testicle status: [Both descended / Cryptorchid: unilateral or bilateral, inguinal or abdominal]
• Spermatic cord ligation: [Method], [Suture material and size]
• Cryptorchid approach (if applicable): [Description], Both testicles removed: [Confirmed]
• Findings: [No abnormalities / Hernia / Mass / Torsion / Other: description]
• Closure: [Method and materials / Left open]

Surgical Complications: [No surgical complications] or [Hemorrhage: source and hemostasis / Organ injury: details / Conversion to extended procedure: reason]

Specimens: [Description and destination] (Omit if no tissue submitted for pathology)

Postoperative Assessment

• Recovery mentation: [Alert / Quiet / Drowsy / Dysphoric / Other]
• Temperature: [Value and unit]
• Pain assessment: [Tool used], [Score or interpretation], [Response to analgesia]
• Incision appearance: [Clean, dry, intact / Serosanguinous / Swelling / Discharge: description]
• Additional recovery medications: [Drug, dose, route, time] (Add lines as needed)

Discharge Readiness: [Alert and responsive / Ambulatory / Vitals stable / Airway reflexes intact / Pain controlled / Normothermic or warming plan]

Disposition: [Same-day discharge / Held for extended recovery: reason / Transferred: destination and reason]

Discharge Medications Prescribed:

• [Medication name and strength] — [Dose], [Route], [Frequency], [Duration], [Quantity dispensed]
• (Add additional medications as needed)

Follow-Up: [Recheck timing], [Suture/staple removal date if applicable], [Special instructions communicated to owner/caretaker]

Signatures

Surgeon: [Name] — I attest that the procedure was performed as documented.

Anesthetist/Monitor: [Name] (if different from surgeon)

Note completed: [Date and time] (Label any late additions with actual event time versus documentation time)