Outlines of Common Surgical Notes

Pre-OP Note ^∗

Date and time:

∗ See also Chapter 24.

Pre-op diagnosis:

Procedure planned:

Staff surgeon:

Pre-op examination:

Pertinent pre-op laboratory studies:

List of routine medications/therapies:

Blood products available:

-Confirm availability with a phone call to the blood bank the night before surgery

Bowel preparation (if any):

Pre-op antibiotics:

VTE prophylaxis:

Steroid preparation (if applicable):

Other special therapies needed:

-PAR statement (a brief statement that the procedure, alternatives, and risks have been discussed with the patient):

-For example, “Procedure, alternatives, benefits, complications, and risks, both foreseen and unforeseen, described in detail to the patient; questions were answered to his/her satisfaction. He/she elects to proceed as planned. Consent signed and witnessed. Surgical site confirmed and marked.”