Writing an operative note

Poor medical records can jeopardise patient care and prejudice medicolegal cases. Here are some tips on doing it well.

• Write clearly and concisely

• Use red ink if possible

• Document the date and time (24 hour clock)

• State the operation performed, including the side (right or left), specific location, type of anaesthesia (general or local), and whether it was an emergency or an elective procedure

• Include the names of the surgeons, anaesthetists, and assistants. State their roles and details of supervision (for example, surgeon A—mobilisation of colon)

• Note the details of the patient's preparation, including positioning (for example, prone), additional procedures (for example, catheterisation) and prophylaxis (for example, antibiotics, heparin)

This is followed by a full description of the operation (based on the template I, F, P, and C):

• Incision type (for example, midline)

• Findings. This should include the pathology discovered during the operation and other unexpected findings, such as anatomical variations

• Procedure. A step by step documentation of the operation should be noted, including major structures preserved, techniques used, intraoperative radiological images and microbiological specimens taken. Diagrams are useful especially in complex operations. Document tissue or bodily fluids removed (such as blood loss). Finally, include the type, size, and serial numbers of prosthesis and sutures used

• Closure technique (including type of dressings used)

And finally, equally important, but commonly forgotten:

• List the postoperative instructions

• Document the name, grade, and signature of person writing the operative note