Surgery Operative Note

Surgery Operative Note

written in the OR, immediately after surgery before the patient is in the PACU, in the progress note section of the chart. Complements the formal operative summary dictated by the surgeon

• • Preop Dx: acute appendicitis

  • Postop Dx: mesenteric lymphadenitis

  • Procedure: exploratory laprotomy

  • Surgeons: X MD,

  • Assistants: Y PA-C, DccIII, MSII, etc.

  • Op. findings: normal appendix with marked lymphadenopathy

  • Anesthesia: GET

  • I/O: fluids amount/type obtained from anesthesia records, UO:

  • EBL: 50 mL, obtained from anesthesia records

  • Specimen: appendix to pathology

  • Drains: Jackson-Pratt drain in RUQ

  • Complications: none

  • Condition: Note where the patient is taken immediately after surgery and Pt's condition.

    • "Transferred to the recovery room in stable condition."