Operative Note: [Procedure, patient identifier, date]
Operation or procedure note written immediately after surgery, so that
another clinician can continue care safely. The content checklist is
mapped to the operative note items in the Royal College of Surgeons of
England, Good Surgical Practice 2025 (published 20 March 2025),
section 3.5 "Record your work clearly, accurately and legibly", item
7, which revised the 2014 edition. The layout is neutral and works for
other countries; use your national or specialty standard where one
applies. Replace every [bracketed] value and every row marked
Example. This is a documentation format, not medical advice; follow
local policy, your specialty's requirements and clinical judgement.
Use fictional data in examples.
Document control
| Field | Value |
|---|
| Document ID | [OPN-YYYY-NNNN] |
| Patient | [Identifiers per facility policy] |
| Date of procedure | YYYY-MM-DD |
| Start / end time | HH:MM / HH:MM |
| Theatre or procedure room | [Site, room] |
| Version | [1.0] |
| Status | [Draft / Signed / Addendum added] |
| Owner | [@operating-surgeon] |
| Approvers/reviewers | [Supervising consultant, if the note is written by a trainee] |
| Last updated | YYYY-MM-DD HH:MM |
| Classification | [Confidential: patient record] |
Revision history
| Version | Date | Author | Change |
|---|
| 1.0 | YYYY-MM-DD | [Name] | Note signed |
| 1.1 (Example) | YYYY-MM-DD | [Name] | Addendum: histology request number added, original text unchanged |
1. Procedure details
| Item | Detail |
|---|
| Procedure performed | [Name of procedure, side and site] |
| Planned procedure | [Same / different: see section 4] |
| Urgency | [Elective / non-elective, with local category] |
| Indication | [Reason for surgery] |
| Pre-operative diagnosis | [Diagnosis] |
| Consent | [Form reference, who consented, risks discussed] |
| Safety checklist completed | [Yes, time of sign in, time out, sign out] |
2. Team
| Role | Name |
|---|
| Operating surgeon | [Name, grade] |
| Supervising consultant (if not operating surgeon) | [Name] |
| Assistant(s) | [Name, grade] |
| Anaesthetist | [Name, grade] |
| Anaesthesia type | [General / regional / local / sedation] |
| Scrub practitioner | [Name] |
3. Operative findings and diagnosis
- Operative findings: [Description]
- Operative diagnosis: [Diagnosis]
Example: fictional patient at Halvermoor District Hospital. Findings: acutely
inflamed, non-perforated appendix; no free pus; terminal ileum normal;
small amount of clear free fluid in the pelvis. Operative diagnosis:
acute appendicitis.
4. Procedure description
| Step | Detail |
|---|
| Position and preparation | [Position, skin preparation, draping] |
| Incision or access | [Type, site, length, port positions] |
| Key steps | [Numbered steps] |
| Extra or changed procedure | [None / what and why] |
| Tissue removed, added or altered | [Specimen, graft, anastomosis] |
| Closure | [Layers, material, skin closure] |
| Dressings | [Type] |
Example: Supine. Chlorhexidine skin preparation. Three ports:
umbilical 12 mm open entry, left iliac fossa 5 mm, suprapubic 5 mm.
Mesoappendix divided with energy device. Base secured with two
absorbable loops and appendix removed in a retrieval bag. Pelvis washed
with warm saline. Port sites closed: umbilical fascia with absorbable
suture, skin with absorbable subcuticular suture. No extra procedure.
5. Specimens, implants and counts
| Item | Detail |
|---|
| Specimens | [Specimen, destination laboratory, request reference] |
| Implants or prostheses | [Device, manufacturer, lot or serial number, unique device identifier] / [None] |
| Drains | [Type, site] / [None] |
| Counts correct | [Yes, confirmed by scrub practitioner] / [No: action taken] |
| Example | Appendix to histopathology; no implants; no drain; counts correct |
6. Complications and blood loss
| Item | Detail |
|---|
| Problems or complications | [None / description and action] |
| Estimated blood loss | [mL] |
| Blood products given | [None / type, units] |
| Example | None; estimated blood loss under 20 mL; no blood products |
7. Prophylaxis
| Item | Detail |
|---|
| Antibiotic prophylaxis | [Drug, dose, time / not indicated] |
| Venous thromboembolism prophylaxis | [Mechanical and pharmacological plan, start time / reason not given] |
8. Postoperative instructions
| Item | Instruction |
|---|
| Observations | [Frequency, escalation thresholds per local early warning policy] |
| Analgesia | [Plan] |
| Fluids and diet | [Plan] |
| Mobilisation | [Plan] |
| Drains, catheters, wound care | [Plan] |
| Medicines to restart or hold | [Plan, see healthcare/medication-reconciliation] |
| Investigations | [Bloods, imaging, timing] |
| Follow-up and results | [Who reviews histology, clinic date] |
| Expected discharge | [Date or criteria] |
| What to watch for | [Specific risks and the action if they occur] |
9. Completeness checklist
| Item in this note | Section | Done |
|---|
| Date and time | Document control | [ ] |
| Elective or non-elective | 1 | [ ] |
| Operating surgeon and assistant names | 2 | [ ] |
| Anaesthetist name | 2 | [ ] |
| Procedure performed | 1 | [ ] |
| Incision | 4 | [ ] |
| Operative diagnosis | 3 | [ ] |
| Operative findings | 3 | [ ] |
| Problems or complications | 6 | [ ] |
| Extra procedure and its reason | 4 | [ ] |
| Tissue removed, added or altered | 4 | [ ] |
| Prosthesis and implant identification, including serial numbers | 5 | [ ] |
| Closure technique | 4 | [ ] |
| Estimated blood loss | 6 | [ ] |
| Antibiotic prophylaxis, where applicable | 7 | [ ] |
| Venous thromboembolism prophylaxis, where applicable | 7 | [ ] |
| Detailed postoperative instructions | 8 | [ ] |
| Signature, handwritten or electronic | 10 | [ ] |
10. Signature
| Item | Detail |
|---|
| Signed by | [Name, grade, professional registration number] |
| Date and time | YYYY-MM-DD HH:MM |
| Addenda | [None / date, author, content] |
References
| Reference | Status | Use |
|---|
| Royal College of Surgeons of England. Good Surgical Practice 2025 (published 20 March 2025), section 3.5, https://www.rcseng.ac.uk/standards-and-research/gsp/ | Checked 2026-10-30 (page and PDF read) | Operative note content items, note travels with the patient |
| World Health Organization. WHO Surgical Safety Checklist (2009) | Cited by name | Safety checklist sign in, time out, sign out |
Standard and licence note
Structure aligned with the operative note content items in the Royal
College of Surgeons of England, Good Surgical Practice 2025, section
3.5 item 7 (page checked 2026-10-30). The guidance is free to read on
the RCS England site; this template names the items in original wording
and does not reproduce the publication. Other countries and specialties
may set different or additional requirements. All names and clinical
details in examples are fictional. This is a documentation format, not
medical advice; check the current official guidance and follow local
policy. Template licence: MIT.