How to Write an Operation Note – OSCE Guide

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Introduction

The operative record serves as an important reference for clinicians to recall the details of a patient’s surgical procedure and plan future management. It is therefore crucial that an accurate and comprehensive record is documented following surgery. The Royal College of Surgeons of England has published a standard that should be adhered to for all operative records.1

The general overview of an operative record is as follows:

  • Patient details
  • Procedure details
  • Operative details
  • Post-op care instructions
  • Sign-offย 

Patient details

The patient’s details should be checked to ensure their accuracy and documented clearly including:

  • Full name
  • Date of birth (dd/mm/yyyy)
  • Hospital number
  • NHS number

Procedure details

It is important to accurately document the circumstances surrounding the operation, including the indication, setting and the members of staff involved:

  • Date and time of the procedure (e.g. 14:30)
  • Location of the procedure (e.g. theatre #3)
  • Elective or emergency procedure
  • Indication for the procedure
  • Name of the procedure
  • Operative findings
  • Operating surgeon(s)
  • Assistants (e.g. registrars, medical students)
  • Anaesthetist and anaesthesia assistants

Operative details

The operative details section should provide an account of the procedure that was performed, to a level that would allow accurate interpretation by another doctor. Operative details are valuable for continuity of care between the hospital and community.

Operative details include:

  • Operative diagnosis (if relevant)
  • Antibiotic prophylaxis: drug name, dose and duration
  • Venous thromboembolism (VTE) prophylaxis
  • Incision (e.g. type, size)
  • A step-by-step account of procedure performed: this section will account for the majority of the operative record and should be detailed enough that someone familiar with the procedure can understand what was performed
  • Immediate problems/complications from the procedure
  • Extra/unanticipated procedures performed and the indication
  • Tissues removed, added or altered
  • Prosthetic material used or implanted including relevant serial numbers (e.g. mechanical heart valve)
  • Closure technique: type and size of suture material(s) and technique(s) used
  • Estimated blood loss: calculated by checking suction bottles and weighing swabs
  • Swab, instrument, sharp count

Post-op care instructions

The post-op section is important as it directs the patient’s care in recovery, on the ward, during their admission and potentially beyond. This section will be much more specific to the patient and operation itself, but some examples of things you may wish to include are:

  • Immediate plan in recovery (e.g. oxygen saturation monitoring)
  • Antibiotic prophylaxis: drug name, dose and duration
  • VTE prophylaxis
  • Blood tests or investigations required
  • Discharge plan: conditions to be met before discharge
  • Follow-up plan: who and when
  • Red flag advice that has been given to the patient (e.g. symptoms or signs to watch out for and advice on what they should do if these symptoms occur)

Sign-off

The person documenting the operative record should sign off the note with the following information:

  • Full name and signature
  • Grade
  • GMC number
  • Contact number (or emergency contact number โ€“ e.g. on-call team)

Example

Below is an example operation note for a simple ENT procedure, tonsillectomy. Whilst some aspects of this example will not be relevant to operations from other specialities, the overall template will be similar.

Operation note

Patient name: Miss Steph Pyogenes

Patient DOB: 08/01/2006

Hospital No: 1234567

NHS No: 404-000-1234

Date: 22/01/2021

Time: 15:00

Location: Theatre 2

Elective or emergency: Elective

Indication: Recurrent tonsilitis โ€“ 7 episodes in past 12 months

Procedure: Bilateral bipolar tonsillectomy

Findings: Bilateral grade 3 tonsils, significant fibrosis in keeping with recurrent tonsilitis

Surgeon: Mr Alex North CT1

Assistant: Mr Rakesh Mistry ST3

Anaesthetist: Dr Jodie Gas

Procedure (step-by-step account):

  • General anaesthetic, supine, WHO checklist completed
  • No antibiotics, TED stockings worn
  • Boyle-Davis gag, Draffin rods
  • Bipolar dissection (10W)
  • Bilateral palatine tonsils removed
  • Haemostasis ensured
  • Post-nasal space suctioned
  • Teeth, lips, tongue and TMJs checked and okay

Complications: No problems, complications or unexpected steps

Specimens:

  • Bilateral tonsils removed – not sent for histology

Closure technique: [No closure required in tonsillectomy, but technique and suture material would be documented here]

Blood loss: Minimal

Equipment count: Swab, instrument and sharps count correct

Post-operative plan:

  1. Immediate plan: monitor oxygen saturations in recovery and inform surgeons if any bleeding
  2. Antibiotics: not required
  3. VTE prophylaxis: not required, can mobilise normally
  4. Blood tests or investigations: none required
  5. Discharge plan: home later today when eating and drinking
  6. Follow-up plan: virtual clinic appointment in 4 weeks in Ms Consultantโ€™s clinic
  7. Red flag advice: return urgently to the emergency department if any significant bleeding from the mouth is experienced post-operatively

Sign off:

  • Alexander North
  • CT1
  • GMC Number: 123456
  • Contact on bleep 6111 or ENT on-call on 6163 if an emergency or out of hours

References

  1. Royal College of Surgeons of England. Record your work clearly, accurately and legibly. Published in 2021. Available from: [LINK]

Reviewer

Rakesh Mistry

ENT Registrar


Editor

Hannah Thomas


ย 

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