How to write an operation note

Authors: Lee Hoggett, Andrew Wright, James Wilson 

Publication date:  24 Jan 2017


Good communication between the surgical team and other colleagues is vital, say Lee Hoggett, Andrew Wright, and James Wilson

An operation note is essential to ensure continuity of care between the operating team and other colleagues, and provides a medicolegal record of a patient’s care. All surgical trainees should know what needs to be detailed in an operation note, and here we present a framework for documenting operations. These principles can also be applied more broadly to any medical procedure.

Notes must be completed immediately after an operation by a member of the operating team. They can be handwritten or, preferably, typed, in line with current guidance from the Royal College of Surgeons of England (RCS). Increasingly, especially in elective cases, there has been a move towards template based operation notes to standardise layout and the postoperative instructions, making them easier to understand. The operation note should accompany the patient into recovery and to the ward and should give enough detail to enable continuity of care by another doctor. The RCS offers comprehensive guidance on what should be included (box).[1]

The record should include the patient’s name, date of birth, and hospital or NHS number; the date and time of the operation; and the names of the operating surgeon, assistants, and anaesthetist. It should also include the specific operation performed, with mention of the site and location, if appropriate, along with method of anaesthesia.

Details of preoperative preparation should follow, including positioning of the patient (for example, supine, prone, lithotomy), additional procedures (such as catheterisation), and any antibiotic prophylaxis.

The remainder of the operation note can be broken down into the following five main parts.

Incision and approach—This should indicate the type of incision or portals used (for example, midline, paramedian, posterior) and approach used. This is particularly helpful should revision surgery be needed.

Findings—All operative findings should be documented here, including the pathology encountered, specifying if it was as expected, and anatomical variations.

Procedure—This should be a step by step account of the operation from incision to closure, starting with any major anatomical structures encountered, then techniques used, tissue excised, prostheses implanted, assisting devices used (image intensifier, gamma probe, tourniquet time), and finally any unexpected complications of the procedure, such as significant blood loss or iatrogenic nerve injury.

Closure—This should cover any structures or layers closed in order (fascia, fat, skin) and the method of closure, including the material and technique.

Postoperative instructions—Here any specific instructions to ensure good postoperative care should be documented. It is good practice to include things such as venous thromboembolism prophylaxis, samples that have been sent for pathology or microbiology, further antibiotics if required, any instructions to multidisciplinary team members (physiotherapists, for example), specific and clear follow-up instructions, and dressing changes and suture removal, if relevant. This section is also commonly used to specify conditions for discharge in day case procedures.

It is important to ensure that any intraoperative images taken are attached to the note (or saved to a picture archiving and communication system (PACS)), together with a record of serial numbers of prostheses implanted.

The document should then be signed, with the signing doctor also documenting his or her name, grade, and General Medical Council number.

Box: What to include in an operation note, from Good Surgical Practice 2014

Date and time

Elective or emergency procedure

Names of operating surgeon and assistant

Name of anaesthetist

Operative procedure

Incision

Operative diagnosis

Findings

Complications

Additional procedures performed and why

Any tissue removed or altered

Any prosthesis used, including serial numbers of the prostheses and other implanted materials

Details of closure technique

Anticipated blood loss

Antibiotic prophylaxis

Deep vein thrombosis prophylaxis

Detailed postoperative care instructions

Signature

Competing interests: None declared.

References

  1. Royal College of Surgeons of England. Good surgical practice. 2014. [Link] .

Lee Hoggett FY2, trauma and orthopaedic surgery
Andrew Wright ST7, trauma and orthopaedic surgery
James Wilson consultant, trauma and orthopaedic surgery Royal Bolton Hospital, Bolton

 Lee.Hoggett@boltonft.nhs.uk

Cite this as BMJ Careers ; doi: