Guidance on writing general surgical operation notes: a review of the literature


  • Tanvir Hossain Department of General Surgery, Nottingham University Hospitals, Nottingham NG7 2UH
  • Naveed Hossain Department of General Surgery, Royal Liverpool University Hospital, Liverpool, Merseyside L7 8XP



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.


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