Guidance on writing general surgical operation notes: a review of the literature
Keywords:Operation notes, Operative documentation
Proficient, legible operation notes are vital for post-operative care, remuneration and defence in litigation. The first typed operation noted can be traced back to over 100 years ago, however increased volumes of work shifted the document to hand-written and then potentially illegible scripts. The pitfalls have been recognised by clinicians worldwide and schemes to type operation notes, using templates, mnemonics and adhere to accepted standards have followed.
Gillman LM, Vergis A, Hardy K, Park J, Taylor M. Resident training and the dictated operative report: a national perspective. Can J Surg (J Canadien de Chirurgie). 2010;53(4):246-50.
Din R, Jena D, Muddu BN. The use of an aide-memoire to improve the quality of operation notes in an orthopaedic unit. Ann Royal Coll Surg Engl. 2001;83(5):319-20.
The Royal College of Surgeons of England. Guidelines for clinicians on medical records, 1994. Available at: https://www.rcseng.ac.uk/publications/docs/med_records.html.
The Royal College of Surgeons of England. Good surgical practice, 2008. Available at: https://www.rcseng.ac.uk/publications/docs/good-surgical-practice-1.
Latimer K, Pendleton C, Martinez A, Subramanian PS, Quinones-Hinojosa A. Insight into glaucoma treatment in the early 1900s: Harvey Cushing’s 1905 operation. Arch Ophthalmol. 2012;130(4):510-3.
Baigrie RJ, Dowling BL, Birch D, Dehn TC. An audit of the quality of operation notes in two district general hospitals. Are we following Royal College guidelines? Ann Royal Coll Surg Engl. 1994;76(1 Suppl):8-10.
Bateman ND, Carney AS, Gibbin KP. An audit of the quality of operation notes in an otolaryngology unit. J Royal Coll Surg Edinburgh. 1999;44(2):94-5.
Hamza A AH, Idris S, Ahmed O. Evaluating the Operative Notes of Patients Undergoing Surgery at Omdurman Teaching Hospital, Sudan. Sch J Appl Med Sci. 2013;1(6):668-72.
O’Bichere A, Sellu D. The quality of operation notes: can simple word processors help? Ann Royal Coll Surg Engl. 1997;79(5 Suppl):204-9.
Park J, Pillarisetty VG, Brennan MF, Jarnagin WR, D'Angelica MI, Dematteo RP, et al. Electronic synoptic operative reporting: assessing the reliability and completeness of synoptic reports for pancreatic resection. J Am Coll Surg. 2010;211(3):308-15.
Rhodes ND, Southern SJ. Digital operation notes: a useful addition to the written record. Ann Plast Surg. 2002;48(6):571-3.
Messahel FM, Al-Qahtani AS. Benchmarking of World Health Organization surgical safety checklist. Saudi Med J. 2009;30(3):422-5.
Flynn MB, Allen DA. The operative note as billing documentation: a preliminary report. Am Surg. 2004;70(7):570-5.
Novitsky YW, Sing RF, Kercher KW, Griffo ML, Matthews BD, Heniford BT. Prospective, blinded evaluation of accuracy of operative reports dictated by surgical residents. Am Surg. 2005;71(8):627-32.
Johari A ZN, Altaf A, Bokhari R. Effectiveness of teaching operation notes to surgical residents. Saudi Surg J. 2013;1(1):8.
Eichholz AC, Van Voorhis BJ, Sorosky JI, Smith BJ, Sood AK. Operative note dictation: should it be taught routinely in residency programs? Obstet Gynecol. 2004;103(2):342-6.