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OT notes

How to write the operative note for common operations. Each page has a blank template you can follow in the case sheet, a filled example, and the points that must be in the note for that operation.

219 operations so far. The steps follow standard operative textbooks and each page lists the book chapter it used. The Indian paperwork (consent, MTP and sterilisation forms, specimens, implants) is linked to its source.

Find a procedure

General Surgery 58

Obstetrics 14

Lower segment caesarean section (LSCS)emergencySpinal (subarachnoid block)
Repeat caesarean section (previous LSCS)electiveSpinal (subarachnoid block)
Peripartum / caesarean hysterectomyemergencyGeneral (often converted from spinal); combined spinal-epidural for planned accreta surgery
B-Lynch uterine compression suture for PPHemergencySpinal (already in place for the caesarean); general if unstable or after vaginal birth
Uterine artery / internal iliac artery ligationemergencyGeneral anaesthesia; the existing spinal or epidural may be continued if the woman is stable and the procedure follows a caesarean
Episiotomy and perineal tear (including OASIS) repairemergencyLocal infiltration with lignocaine 1% for episiotomy and first or second degree tears; spinal or general anaesthesia in OT for third and fourth degree tears
Instrumental vaginal delivery (vacuum / forceps)emergencyPudendal block with perineal infiltration (lignocaine 1%) or existing epidural top-up for outlet and low deliveries; spinal or epidural in OT for mid-cavity or trial of instrumental delivery
Manual removal of placentaemergencySpinal or epidural top-up; general anaesthesia if haemodynamically unstable or urgent
Cervical cerclage (McDonald / Shirodkar)electiveSpinal
Laparotomy / laparoscopy for ruptured ectopic pregnancyemergencyGeneral anaesthesia
Suction evacuation / MTP (first trimester)electiveParacervical block with 1% lignocaine, with or without IV sedation; short general anaesthesia in some units
Postpartum / interval minilap tubal ligation (Pomeroy)electiveLocal infiltration with 1% lignocaine with IM/IV sedation-analgesia (recommended by the national sterilisation standards); spinal or GA only where full anaesthesia back-up exists
Exploration of cervix and repair of cervical tearemergencyIM sedation with local infiltration in the labour room for one or two small tears in a stable, cooperative woman; general anaesthesia in OT for heavy bleeding, multiple tears, extension to the fornix or severe pain
Assisted breech delivery / breech extraction (incl. second twin, internal podalic version)emergencyEpidural analgesia if running (preferred for twin delivery), or no regional block with local infiltration for the episiotomy; anaesthetist present in the second stage so that general anaesthesia can be given quickly for extended arms, head entrapment or internal version

Gynaecology 20

Orthopaedics 45

Urology 19

ENT 21

Ophthalmology 20

Paediatric Surgery 3

Neurosurgery 5

OMFS 4

Thoracic / Trauma 10

What every operative note must contain

This list is from the Royal College of Surgeons of England, Good Surgical Practice (2025), section 3.5. Indian audits of operative notes use the same list. Every template on this site starts and ends with these fields.

Date and time
Elective or non-elective
Operating surgeon and assistant
Anaesthetist
Operation done
Incision
Operative diagnosis
Operative findings
Problems or complications
Any extra procedure, and why
Tissue removed, added or altered
Implants, with serial numbers
Closure technique
Estimated blood loss
Antibiotic prophylaxis
DVT prophylaxis
Detailed post-operative instructions
Signature

What Indian rules add

NABH asks for the operative note to be written before the patient is moved out of recovery, and for post-operative care to follow a written plan (NABH 5th edition, COP.14 e and f).
Batch and serial numbers of implants must be in the case sheet, the OT master logbook and the discharge summary (NABH 5th edition, MOM.10 d). Stick the implant stickers in all three.
Consent must be in a language the patient understands. An extra procedure without consent is defensible only when it was needed to save life or health (Samira Kohli v. Dr Prabha Manchanda, Supreme Court, 2008).
Tissue not sent for HPE is yellow-bag human anatomical waste, and discarded formalin is chemical waste (Bio-Medical Waste Management Rules, 2016).
Under AB PM-JAY, the note must match the booked package (procedure, anaesthesia type) and carry the surgeon's registration number.

How Indian hospitals score

Audits from Indian hospitals keep finding the same gaps: tourniquet time, blood loss, closure details, and the words "no complications" are often missing. At Dr RML Institute, Lucknow, a printed proforma raised the share of documented items from 35.8% to 90.2% (Aslam et al., Cureus 2025, PMID 40546492). At a Mumbai tertiary hospital, closure was documented in 17% of notes and blood loss in 59.5% (Tuteja et al., Indian J Orthop 2022, PMID 36507202).