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Surgery

Surgical documentation standards from clerking to post-operative care.

Documentation Overview

Surgical documentation encompasses the full patient pathway: pre-operative assessment and consent, operative findings, post-operative orders and discharge. Accurate documentation is both a patient safety imperative and a medico-legal requirement.

Key Documentation Standards

  • Pre-operative assessment documented including anaesthetic risk
  • WHO Surgical Safety Checklist completed and documented
  • Informed consent obtained and documented before procedure
  • Operative note completed immediately post-procedure by operating surgeon
  • Post-operative instructions clearly documented
  • VTE risk assessment and prophylaxis documented pre-operatively

Common Documentation Scenarios

  • Elective surgery — pre-op assessment, consent, operative note, discharge
  • Emergency surgery — urgent clerking, consent, operative note
  • Post-operative complication — clear documentation of recognition and response
  • Day case surgery — pre-op checklist, discharge criteria met
  • Laparoscopic conversion to open — document decision and findings
  • Return to theatre — document indication and findings

Relevant Templates

Quick Reference
SURGICAL DOCUMENTATION CHECKLIST
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PRE-OPERATIVE
□ Surgical clerking complete
□ Anaesthetic assessment documented
□ VTE risk and prophylaxis plan
□ Consent form completed
□ Mark site confirmed
□ Fasting status documented

INTRA-OPERATIVE
□ WHO checklist: Sign In completed
□ WHO checklist: Time Out completed
□ WHO checklist: Sign Out completed
□ Operative note dictated / written

OPERATIVE NOTE MUST INCLUDE:
□ Indication
□ Procedure performed
□ Findings
□ Technique
□ Complications
□ Specimens
□ Post-op instructions

POST-OPERATIVE
□ Post-op orders written
□ Analgesia plan documented
□ DVT prophylaxis prescribed
□ Drain / catheter instructions
□ Review criteria documented
Specialty-specific: Always refer to your hospital's specialty-specific documentation policies and national guidelines.