How to write a Brief Operative Note

A clinical clerk can write a brief operative note for a surgical patient.

What is a Brief Operative Note?

A brief operative note is NOT the same as the main Operative Note the surgeon writes. This is a quick bullet form in the patient’s chart of the surgery that was performed, which includes details about the procedure, any complications encountered during surgery, and any other relevant information

Outline of a Brief Operative Note

Here is what’s included:

• Pre-Op Diagnosis: Provide the diagnosis recorded prior to surgery taking place.

• Post-Op Diagnosis: Document any changes to the diagnosis after surgery

• Procedure: Include the name of the procedure performed

• Surgeon: Name of the surgeon who performed the procedure

• Assists: List the names of any surgical assistants who were involved in the procedure (include name and designations)

• Anesthesia: Name of anesthesiologist/anesthesia assistant (AA) and type of anesthesia used (e.g. General, Regional)

• Blood Loss: Estimated Blood Loss during surgery, usually the circulating nurse will announce this (e.g. minimal or 125 cc EBL).

• Complications: Include any complications or issues that arose during or after the surgery.

• Drains: List the drains

• Plan/Post-Procedure Care:

  • Disposition : Document where the patient will be transferred to after the surgery (e.g. PACU to the floor or PACU to day surgery unit)

  • Orders for PACU: Include any orders for fluids, pain medications, or other treatments that are required for the patient's immediate post-operative care in the PACU

Example Operative Note for a General Surgery Patient

GENERAL SURGERY OPERATIVE NOTE

• Pre-Op Diagnosis: Acute Cholecystitis

• Post-Op Diagnosis: Acute Cholecystitis

• Procedure: Laparoscopic Cholecystectomy

• Surgeon: Dr. ____

• Assists:

  • Jane Langhorn, PA-S2

  • John Doe, PGY3.

• Anesthesia: Dr. Y, General Anesthesia

• Estimated Blood Loss (EBL): Minimal

• Complications: None

• Drains: None

• Plan:

  • In PACU:

  • Vital Signs q15 min first hour, q30 min next 2 hours, then vital signs routine thereafter

    1. O2 nasal cannual @ 2L/min

  • Transfer from PACU to 9B Floor

  • Acute Pain Service consult for pain management

  • Sips to Diet as tolerated

  • WBAT and AAT

  • Incentive spirometry every hour while awake

  • No VTE prophylaxis

  • Discharge when tolerating regular diet, WBAT independently, and pain well controlled on PO pain meds

Jane Langhorn, PA-S2
Clinical Clerk, General Surgery

In service of: Dr. ______