Operative notes document what occurs during and after a surgical procedure, are written immediately after an operation by a member of the operating team, and are important for ensuring continuity of care, providing a legal record of patient care, and communicating findings, details of the procedure, and post-operative care instructions. They include details of the operation, findings during surgery, post-op instructions, and are saved digitally on the surgeon's laptop and filed by diagnosis, patient name, and hospital number.
1. Operative notes are medical records that document what
happened during a surgical procedure and post-operative
instructions. They are written by a member of the
operating team immediately after the operation.
Operative notes are important for:
•Ensuring continuity of care between the operating team
and other colleagues
•Providing a medicolegal record of a patient's care
•Communicating operative findings and procedure details
•Providing information on post-operative patient care
Operative notes include:
•What operation a patient had
•What was found during surgery
•Post-operative instructions from the surgeon
•Procedure details
•Operative details
•Sign-off
Operative notes are saved on the surgeon's laptop
computer along with the original digital images. They are
filed in folders according to the diagnosis and individually
using a combination of the patient's name and hospital
number
