The operation note (often termed the “op note”) is a vital document that records exactly what operation a patient had, what was found during surgery, and what the post-operative instructions from the surgeon are.
It also provides part of the medicolegal record of a patient’s care during their stay in hospital. As such it is a key document and must contain certain information (as detailed by the Royal College of Surgeons of England in “Good Surgical Practice”)
In this article, we will outline what should be included in an operation note; the principles discussed here may also be applied to other medical procedures.
General Principles
All operations notes must be completed immediately after an operation by a member of the operating team (either be handwritten or typed). All operation notes should be filed within the patient’s current medical notes as the most recent entry, and accompany the patient to recovery and then the ward.
Making sure the operation note, including the post-operative instructions, is written clearly and concisely is absolutely essential. The Royal College of Surgeons (RCS) have outlined a comprehensive guidance on what should be included in concordance with Best Surgical Practice (see below).
RCS Guide for Good Surgical Practice in the Operation Note
- Date and time, elective or emergency procedure
- Names of operating surgeon, surgical assistant, and anaesthetist
- Name of the operative procedure, with the incision made
- The operative diagnosis and the findings
- Complications and any additional procedures performed (and why)
- Any tissue removed or altered, and any prosthesis used (including relevant serial numbers)
- Details of closure technique, with the estimated blood loss
- Antibiotic and DVT prophylaxis
- Detailed postoperative care instructions
Operation Details
There are several specific aspects of the operation itself that must be included and laid out with the operation note.
The incision documented should indicate the site(s) or type of incision made, such as midline, Pfannenstiel, etc. If the procedure has been carried out laparoscopically, it may be beneficial to draw the sites of incisions made on a diagram and label each incision with the size of port(s) used.
As part of the operative diagnosis, the intra-operative findings should be described briefly, including any and all pathologies. If any images are taken during the procedure, these should be attached to the operation note, as a reference.
The procedure described should be an accurate account of the all the steps carried out in the procedure, from the first skin incision to closure. This may contain relevant ligation of vessels, implants and prostheses used, any tissue excised, and the anatomical structures identified and variations.
The closure recorded should include the layers that have been closed, such as fascia/fat/skin; and the material(s) utilised. Any complications discovered intra-operatively should be accurately described, with any specimens taken and the estimated blood loss (written in mLs) recorded.
Completing the Operation Note
Post-operative instructions should be accurately recorded, to document any specific plans to be carried out after the procedure to ensure good post-operative care. This includes any medications to be given, if the patient may eat and drink, if able to be discharged home, and any follow up action required (including dressing changes or suture removal)
Once the operation note has been written, this document should then be signed and dated, with the signing doctor including their name, grade, and registration number.
Key Points
- The operation note documents what operation a patient had, what was found during surgery, and what the post-operative instructions from the surgeon are
- All operations notes must be completed immediately after an operation by a member of the operating team
- The Royal College of Surgeons have outlined a comprehensive guidance on what should be included in concordance with Best Surgical Practice
- Once the operation note has been written, it should be signed and dated, with the signing doctor including their name, grade, and registration number