Operative Notes

A useful template is;

• Name of procedure
• Indication
• Preparation and prophylaxis
• Incision
• Findings
• Procedure, including swabs taken and specimens sent to lab
• Closure, including drains
• Post operative instructions

Include which theater, type of anaesthesia, antibiotics given, fluid and blood products given, operative findings, description of operation, specimens sent and drains/tubes inserted.

Also note in the chart - Date, Time, Operation, Findings, Anaesthesia, Blood losses, Fluid and blood products given, problems encountered and post operative instructions.

Examples;