Documentation of the Procedure

Remember to include standard surgical procedure documentation information:
  • Pre-procedure diagnosis
  • Post-procedure diagnosis
  • Procedure performed
  • Attending and resident physicians
  • Consent and time out
  • Anesthesia used
  • Procedure and findings, including estimated blood loss
  • Complications
  • Postoperative instructions

Consider using this procedure documentation template (.doc). Check with your attending physician to make sure it meets his or her approval.