Operative Note
The brief operative note, written in the chart immediately after the case and before the full dictation.
Pre-op diagnosis
The diagnosis the patient came to the operating room with.
Post-op diagnosis
What you actually found. Often the same, sometimes not.
Procedure
Surgery performed.
Surgeons
Attending, residents, and the students who scrubbed.
Findings
Acutely inflamed gallbladder, 4 cm diameter cyst, and so on.
Anesthesia
General endotracheal (GETA), spinal, local.
Fluids
Amount and type: electrolytes, blood, in cc or units.
Estimated blood loss
Amount in cc.
Drains
Type and location, such as a T-tube in the right upper quadrant.
Specimens
Type sent to pathology, such as gallbladder and cystic duct.
Complications
List them, or none.
Condition
Stable, extubated, transferred to the recovery room.