This operative note template is designed to help attending surgeons and their assistants or fellows to document surgical procedures clearly and accurately. It can also be used as a reference by medical and nursing students who are currently taking lessons on operative notes.
By using this template with Heidi, an AI-powered medical scribe, you can enhance the way you document operative notes by:
Establishing a meticulous recording of essential details such as pre-operative diagnosis, procedures performed, surgical approach, instruments used, intraoperative findings, and post-operative instructions, and summarizes them for ease of use for the post-operative care team or referring physicians.
Achieving peak organization as Heidi automatically arranges key information in your chosen format, making your notes easily understandable, particularly for medical coding, billing, research, and legal documentation.
Helping provide the patient with a comprehensible summary of their follow-up care and medication plans, and guides them in understanding their recovery plan better.
An , also called an op note or surgical procedure note template, is a medical record that documents a surgical procedure, findings, and post-operative instructions. It is vital documentation that helps clinicians review surgical events and guide future patient care.
In this article, we’ll examine research-based findings on the impact of using operative note templates in improving surgical documentation, types of operative note templates, and how to write concise yet accurate operative notes.
Lastly, we’ll share with you operative note templates designed by fellow industry professionals, which you can directly customize according to your preferred format.
The Impact of Operative Note Templates
Utilizing a template for operative notes is more than just about convenience. It has been scientifically proven to improve accuracy and compliance with standards.
A university study found that template-based operation notes are nearly four times more complete than traditional free-text notes (79.2% vs 25%), helping surgeons avoid missing key procedural details.
Further, another research in a hospital showed that digital version of operative notes templates completely reduced documentation delays (from an average of 11.6 days to 0) and improved adherence to surgical guidelines (71.1% to 100%).
In addition, here are more reasons to use operative note templates:
Enhances Post-Operative Care for the Patient
A well-documented operative note ensures that follow-up physicians or therapists can clearly understand the procedure performed and post-operative care instructions, leading to better patient outcomes and continuity of care.
Surgeons have attested on the significant improvements structured operative note templates have contributed on their post-surgical documentation. One such example is Dr. Richard Bloom, who discovered Heidi for his operative reports and reported that it added a new layer of consistency and thoroughness to his workflow.
He mentioned, “I wasn't expecting to use it for operating reports. It's a really good use for it.”. Further, he added, “It's way more accurate than what my handwritten notes were. I'm sometimes even surprised by some of the things that it includes… I read the output and think, actually, we did talk about that!”
Just like how it made a big impact in Dr. Bloom’s post-op notes, Heidi can help ensure you have top-notch surgical documentation. Watch a quick video on how it works:
Improves Medical Coding Accuracy
Templates for operative notes help surgical teams provide more accurate information, which then helps make it easier for coders and billing specialists alike to dissect key details and assign the correct CPT, ICD-10, and HCPCS codes, reducing claim denials and financial discrepancies.
Enhances Legal and Compliance Protection
Properly structured operation notes also help meet regulatory and hospital documentation standards, reducing the risk of audit failures, legal disputes, and compliance violations due to missing or unclear information.
Different Types of Operative Note Templates
Operative note templates are used across various surgical specialties. While the core elements remain fairly similar, different types of surgeries may require specific details tailored to the procedure type. Below are some of the most commonly used operative note templates designed for several surgical procedures:
1. General Surgery Operative Note Template
This type of operative note template is often used in hospitals for common general surgical procedures such as appendectomies, cholecystectomies, and hernia repairs. This type typically includes:
Pre- and post-operative diagnoses
Surgical approach (open vs. laparoscopic)
Key intraoperative findings and technique
Closure method and estimated blood loss
Post-operative instructions and follow-up plan
2. Specialty Surgery Operative Note Template
Operative note templates are also available for different types of surgical specialties, with the aim to capture the unique nuances for each. Below are some examples of specialty-specific operative note templates:
Feel free to check other types of AI-enabled templates by visiting the Heidi Community and explore more professionally-crafted templates for operative notes and beyond.
How To Write an Operative Note with Examples
When writing an operative note, it is imperative to include all essential information related to the surgical procedure while ensuring that they are written concisely. With that, below are the critical components to include in your operative note, with an example for each section:
1. Patient Name, Date, Time, and Location
Accurately identify the patient and include all relevant details about the date and time when the procedure occurred. Also ensure that the name of the surgeon and assisting staff are precisely listed. Here’s is a sample entry:
Patient Name: Denver Florence
Date of Birth: March 12, 1975
Patient ID: 12345678
Date of Surgery: February 5, 2025
Time of Surgery: 10:30 AM – 11:30 AM
Location: City General Hospital – OR
Primary Surgeon: Dr. Emily Roberts
Assistants: Dr. James Pugh, Dr. Sarah Kim (Anesthetist)
2. Diagnosis and Procedure Performed
This section is where you clearly define the surgical rationale, ensuring both pre-operative and post-operative diagnoses are accurately recorded. It establishes why the surgery was necessary and confirms whether the initial diagnosis was correct or if intraoperative findings led to a revised diagnosis. For example:
Pre-Operative Diagnosis: Recurrent right lower quadrant pain with fever, elevated white blood cell count, and CT findings suggestive of acute appendicitis.
The patient presented with classic symptoms and imaging findings consistent with appendicitis, requiring urgent surgical intervention to prevent complications such as perforation or abscess formation.
Post-Operative Diagnosis: Perforated appendicitis with localized peritonitis.
Intraoperative examination revealed a perforated appendix with surrounding inflammation, confirming that immediate appendectomy was necessary to remove the source of infection and prevent further complications.
Procedure Performed: Laparoscopic appendectomy.
The procedure was performed using a minimally invasive approach, which is preferred due to its benefits of reduced post-operative pain, shorter hospital stay, and faster recovery compared to an open appendectomy.
Additional Findings or Modifications: Dense adhesions noted intraoperatively, requiring careful dissection to prevent injury to surrounding structures.
The presence of adhesions prolonged the procedure but did not require conversion to an open approach, allowing for a successful laparoscopic intervention.
3. Surgical Details
This section outlines the technical aspects of the procedure, including type of anesthesia used, step-by-step surgical approach, specimens removed, estimated blood loss, and any intraoperative complications. See example below:
Type of Anesthesia: General anesthesia
Surgical Steps:
Patient positioned supine, prepped, and draped in sterile fashion.
Pneumoperitoneum established with a Veress needle at the umbilicus.
Trocar placement: 10mm umbilical port, 5mm left lower quadrant port, 5mm right lower quadrant port.
Appendix identified with surrounding inflammation and adhesions to the cecum.
Adhesions carefully dissected to expose the base of the appendix.
Appendiceal artery and mesoappendix cauterized and ligated.
Appendix stapled and removed through the umbilical port using an endobag.
Abdominal cavity irrigated to clear any purulent fluid.
Hemostasis confirmed, trocars removed, and incisions closed with sutures and skin adhesive.
Specimens Removed: Appendix sent for histopathology.
Estimated Blood Loss (EBL): Less than 20 mL.
Complications: None.
4. Post-Operative Plan
This section provides clear, structured instructions for post-operative care, pain management, and follow-up to ensure a smooth recovery and prevent complications. It should outline medication plans, activity restrictions, wound care, dietary recommendations, and follow-up appointments. For instance:
Patient’s Condition: Stable, extubated in the OR, and transferred to the recovery room in good condition.
Pain Management: IV acetaminophen 1g every 6 hours as needed, oral ibuprofen 400mg every 8 hours as needed.
Antibiotics: IV piperacillin-tazobactam 3.375g every 8 hours for 24 hours, then transition to oral amoxicillin-clavulanate for 5 days.
DVT Prophylaxis: Early ambulation encouraged; no heparin required due to low risk.
Diet: Clear liquids once awake, advance to a soft diet as tolerated.
Activity Level: Walk after 6 hours, avoid strenuous activity or heavy lifting for 2 weeks.
Follow-Up Plan:
Clinic visit in 7-10 days for wound check and staple removal (if applicable).
Pathology results to be reviewed at follow-up.
Monitor for fever, worsening pain, nausea, or signs of wound infection.
5. Signature and Date
The primary surgeon must sign and date the report to confirm its accuracy and legal validity.
Surgeon: Dr. Emily Roberts
Date: February 5, 2025
Time of Note Completion: 11:55 AM
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Operative Note Template Example
You can download a copy of this document, or auto-fill it seamlessly with Heidi, your AI care partner.
Manually filling out operative notes can be time-consuming and prone to inconsistencies and that’s where operative note templates can help. However, did you know that you can take that improved efficiency a step further? That’s where Heidi, an AI-powered medical scribe, steps in.
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Top Notch Surgical Documentation with Heidi’s Operative Note Templates
With Heidi, you can automate and refine operative note documentation to make the process faster, more accurate, and effortless. Here’s how:
Transcribe - During surgery, simply speak key details aloud, and Heidi automatically captures the critical procedural steps, surgical techniques, and intraoperative findings in real-time.
Customize - Heidi then continues its magic and organizes the details into your chosen operative note template, ensuring that all required fields are filled—from anesthesia details and incision technique to estimated blood loss and post-op instructions.
Transform - You can also instantly generate detailed patient summaries, and post-op instructions ensuring a seamless handover between teams. This also helps make it easier to extract codes efficiently, reducing billing errors and ensuring streamlined processes.
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Yes, operative note templates can be customized to fit different surgical procedures, making sure that all the pertinent details unique to a particular procedure are recorded properly. With Heidi, surgeons can create structured templates that fit their needs, making documentation adaptable whenever needed.
