Operative Note Template
The contemporaneous record of what was done in theatre. It is the document another surgeon relies on if the patient returns, and the one that answers what was used, what was found and what was decided when the plan changed.
When it is used
Immediately after the procedure, before leaving theatre where possible.
The template
OPERATIVE NOTE Date: Surgeon: Assistant: Anaesthetist: Anaesthesia: general / regional / local / sedation INDICATION Diagnosis: Planned procedure: Consent confirmed: yes / no Site marked: yes / no / not applicable WHO checklist completed: yes / no FINDINGS Intra-operative findings: Deviation from expected anatomy: PROCEDURE PERFORMED Position: Preparation and draping: Incision: Approach and dissection: Technique: Deviation from planned procedure, with reason: IMPLANTS, DEVICES AND MATERIALS Item / manufacturer / size / lot or serial number: Grafts used: Sutures used: HAEMOSTASIS AND CLOSURE Haemostasis: Drains (type and site): Closure in layers: Dressings: SPECIMENS Specimen / site / labelling / destination: MEASUREMENTS AND TIMES Estimated blood loss: Tourniquet time: Operative time: Counts correct: yes / no POST-OPERATIVE INSTRUCTIONS Analgesia: Antibiotics: Thromboprophylaxis: Weight-bearing / activity restrictions: Wound care: Drain management and removal: Red flags for the ward or patient: Follow-up:
Free to use and adapt. It is a structure, not clinical or legal advice — your records remain your professional responsibility.
Completed example
The same structure filled in, so you can see the level of detail it is built for. Details are illustrative and not from a real patient.
OPERATIVE NOTE Date: 14 March 2026 Surgeon: [name] Assistant: [name] Anaesthetist: [name] Anaesthesia: general with laryngeal mask INDICATION Bilateral breast hypoplasia with mild ptosis. Planned: bilateral dual-plane augmentation. Consent confirmed. Site marked. WHO checklist completed. FINDINGS Thin upper pole soft tissue bilaterally, as anticipated. Pectoralis major well developed. No breast masses palpable under anaesthesia. Inframammary folds symmetrical. PROCEDURE PERFORMED Supine, arms abducted 60 degrees. Chlorhexidine prep, standard draping. Bilateral 4.5cm inframammary incisions. Dissection to pectoral fascia, subpectoral pocket developed with release of inferomedial origin to the level of the fold — dual-plane type I. Sizers placed, position and symmetry assessed sitting at 45 degrees. No deviation from planned procedure. IMPLANTS Right: [manufacturer] anatomical textured, 295cc, lot [number] Left: [manufacturer] anatomical textured, 280cc, lot [number] Sizing difference to address pre-existing asymmetry. Sutures: 2-0 absorbable fascia, 3-0 absorbable deep dermal, 4-0 absorbable subcuticular. HAEMOSTASIS AND CLOSURE Haemostasis with bipolar. No drains. Closure in three layers. Adhesive strips and supportive dressing. SPECIMENS None sent. MEASUREMENTS AND TIMES Estimated blood loss: under 50ml. Operative time: 95 minutes. Counts correct. POST-OPERATIVE INSTRUCTIONS Analgesia: regular paracetamol and ibuprofen, codeine as required. Antibiotics: single intra-operative dose; none on discharge. Thromboprophylaxis: early mobilisation, stockings until discharge. Supportive garment continuously for six weeks. No upper body resistance work for six weeks; cardiovascular exercise from week four. Red flags: unilateral swelling, fever, increasing unilateral pain. Follow-up: wound check at one week, review at three weeks.
Documentation considerations
- Record findings before the procedure performed. Findings justify what followed.
- Any departure from the planned procedure needs the reason stated, not just the change.
- Implants and devices need lot or serial numbers. A note recording "implant inserted" cannot support a recall.
- Specimens sent for histology should be listed individually with their labelling.
- Counts, tourniquet times and drain positions are the details nobody remembers and everybody later needs.
Have this filled in for you
Patien listens to the encounter and returns the note in this structure. Templates are editable, so if your headings differ from these, change them once and every note follows.
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