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Clinical noteSurgery

Operative Note

Full operative report with pre- and postoperative diagnoses, procedures, surgical team, anesthesia, indications, findings, detailed description, and counts.

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Layout preview with this template’s real sections. The content comes from your visit.
  1. Choose this templatePick it when you start a visit, or make it your default.
  2. Record the visitIn the room, over telehealth, or by dictation afterwards.
  3. Review, edit and signThe draft arrives in these sections, ready for your review.

What’s in this template

16 sections, in the order they appear in the finished document.

  1. 1Preoperative DiagnosisAuto
  2. 2Postoperative DiagnosisAuto
  3. 3Procedure(s) PerformedNumbered list
  4. 4Surgeon & AssistantsBullets
  5. 5AnesthesiaParagraph
  6. 6IndicationsParagraph
  7. 7FindingsBullets
  8. 8Description of ProcedureParagraph
  9. 9SpecimensBullets
  10. 10ImplantsBullets
  11. 11DrainsBullets
  12. 12Estimated Blood Loss, Fluids & Urine OutputBullets
  13. 13CountsParagraph
  14. 14ComplicationsParagraph
  15. 15Condition & DispositionParagraph
  16. 16Postoperative PlanBullets

“Auto” sections use whichever format reads most clearly for what was discussed: prose or a list.

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