# 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.

<!--
Guidance: How to use this template
- Write the note at the end of the procedure, before the patient leaves
  recovery. RCS England guidance asks that the note goes with the
  patient to recovery and the ward and is preferably typed.
- Write for the clinician who will see the patient at 03:00 without
  you: what was done, what was found, what to watch for and what to do.
- Record implant identifiers exactly (manufacturer, lot or serial
  number, unique device identifier where available). They are needed
  for recalls and registries.
- Any change from the planned procedure needs a reason and, where
  relevant, a note on how consent covered it.
- Use the checklist in section 9 before signing.
- Related templates: History and Physical
  (`healthcare/history-physical`), Progress Note
  (`healthcare/progress-note`), Discharge Summary
  (`healthcare/discharge-summary`), Patient Safety Incident Report
  (`healthcare/patient-safety-incident-report`) for an unexpected event,
  Clinical Audit (`healthcare/clinical-audit`) to audit note quality.
-->

## Document control

<!-- Guidance: In most electronic records the system fills these fields. Keep them for a typed or exported note so it is traceable. -->

| 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

<!-- Guidance: State urgency with your local classification. RCS England refers to its own classification of non-elective surgery; many units use the NCEPOD classification of intervention. -->

| 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

<!-- Guidance: Record full names and roles. The operating surgeon is the person who did the key steps; name the supervising consultant if different. -->

| 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

<!-- Guidance: Describe what you found, including normal findings that matter for later decisions. Give the operative diagnosis even when it matches the pre-operative one. -->

- 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

<!-- Guidance: Number the steps in order. Include position, preparation, incision or port sites, key steps, any extra procedure with its reason, haemostasis and closure. -->

| 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

<!-- Guidance: Record every specimen sent and every implant used. Swab, instrument and sharps counts confirm nothing was left in the patient. -->

| 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

<!-- Guidance: Record any problem or complication in theatre, even if resolved. An unexpected event may also need an incident report. -->

| 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

<!-- Guidance: State what was given and when, or why it was not given. -->

| Item | Detail |
|---|---|
| Antibiotic prophylaxis | [Drug, dose, time / not indicated] |
| Venous thromboembolism prophylaxis | [Mechanical and pharmacological plan, start time / reason not given] |

## 8. Postoperative instructions

<!-- Guidance: Detailed, specific instructions with time frames. The ward team should not need to call you to find out what to do. -->

| 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

<!-- Guidance: Each row maps to a content item listed in Good Surgical Practice 2025, section 3.5 item 7, paraphrased here. Tick before signing. -->

| 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 | [ ] |

```mermaid
flowchart LR
    A["Procedure ends"] --> B["Write note in theatre"]
    B --> C{"Checklist complete?"}
    C -- "No" --> B
    C -- "Yes" --> D["Sign"]
    D --> E["Note travels with patient to recovery and ward"]
```

## 10. Signature

<!-- Guidance: Sign with name, grade and registration number. Corrections after signing go in a dated addendum; never overwrite the original. -->

| Item | Detail |
|---|---|
| Signed by | [Name, grade, professional registration number] |
| Date and time | YYYY-MM-DD HH:MM |
| Addenda | [None / date, author, content] |

## References

<!-- Guidance: Name your national or specialty standard if it differs, and its edition. -->

| 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.