Operative notes
About surgery: What should go in surgical notes?
What is the diagnosis?
Who verified the diagnosis?
What type of procedure was done?
How was the procedure done?
How long did the procedure last?
Where was the procedure done?
What were the findings?
Who verified the findings?
What are the post-operative instructions?
How could this be prevented?
What were the intraoperative findings?
How long will the incision be? or
How long was the incision?
Was any tissue removed?
What type of tissue was removed?
Was the specimen preserved?
Was there any intraoperative complication?
How could this be prevented?
What are the operative details?
Who verified the findings?
How will the wound be closed? or
How was the wound closed?
What materials will be used to close the wound? or
What materials were used to close the wound?
Who was present in the operating room?