Free template · PDF
Operative note template
The procedure note in the order a colleague reads it the next morning, from indication to post-procedure plan.
Download the PDFFree, no sign-up. Fill it in on screen or print it.
What is on the form
- Practice letterhead, date and reference
- Patient: name, date of birth, MRN and address
- Date, time, consultant, location and anaesthesia
- Diagnosis and indication
- Procedure performed and technique
- Findings, specimens and devices
- Complications, blood loss and condition
- Post-procedure plan and instructions
- Follow-up
- Sign-off: name, qualifications and Irish Medical Council number
Using it well
- Record implants and devices with the detail your hospital's traceability process asks for.
- Write the post-procedure plan so the ward team can act on it without phoning.
Less paperwork to fill in at all.
In Ask Brigid, consult dictation returns a transcript in the patient record for you to review, next to the diary and the inbox. Theatre lists and procedures for private urologists.
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