Operative Note Template

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After induction of general anesthesia, the genitals were prepped and draped in the usual fashion. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. At this time, all instruments were removed.

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Also, of note is that prior to the insertion of the hysteroscope, endocervical curettage was performed, and those curettings were also sent to pathology.

The patient was dismissed from the practice because of Patient Dismissal Reason.

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Creating new documents for every surgical procedures can be a total waste of the time and money. Pre-Op Diagnosis: gallstone pancreatitis Post-Op Diagnosis: same Procedure: Laparoscopic cholecystectomy with Intraoperative cholangiogram Surgeon: Lin Assistants: Resident, MS Remember, an op note is a legal document that can only be altered by a physician, so make every effort to ensure template operative reports are updated and augmented to accurately and consistently reflect the procedure as it was performed (not just as it was planned). They are provided to help visualize the procedure from beginning to end and to illustrate key points and staff preferences.