Documenting a general surgery list
Operation notes dictated between cases, post-operative ward notes, histology letters and the reply to the referring GP.
An operation note dictated before the next case
Laparoscopic cholecystectomy. Recurrent biliary colic, gallstones on ultrasound, LFTs normal.
Open Hasson entry at the umbilicus, four ports. Gallbladder thick-walled with omental adhesions, no acute inflammation.
Critical view of safety achieved. Cystic artery and cystic duct clipped and divided. Gallbladder off the liver bed with diathermy, haemostasis checked, out in a bag through the umbilicus.
No drain. Umbilical fascia 0 PDS, skin 4-0 Monocryl subcuticular, 20 mL of ropivacaine to the ports.
Gallbladder to histology. Blood loss minimal. Day surgery, home tonight once she's passed urine. Paracetamol and ibuprofen regular, oxycodone 5 for breakthrough. Rooms in two weeks.
Indication
Recurrent biliary colic. Cholelithiasis on ultrasound. LFTs normal.
Procedure
Laparoscopic cholecystectomy. Open Hasson entry at the umbilicus, 4 ports. Critical view of safety achieved. Cystic artery and cystic duct clipped and divided. Gallbladder dissected from the liver bed with diathermy, haemostasis confirmed, retrieved in a bag via the umbilical port.
Findings
Thick-walled gallbladder with omental adhesions. No acute inflammation.
Specimens
Gallbladder to histology.
Closure
Umbilical fascia 0 PDS. Skin 4-0 Monocryl subcuticular. Ports infiltrated with ropivacaine 20 mL. No drain.
Complications
Nil. EBL minimal.
Plan
- Day surgery discharge once voided
- Paracetamol and ibuprofen regular, oxycodone 5 mg PRN
- Review in rooms in 2 weeks
After the list
- Procedure note
- Dictated between cases and signed before the patient leaves recovery.
- Discharge letter
- For a day case: the operation, wound care, analgesia, when to drive and the rooms review date.
- Histology letter
- To the GP when the pathology report is uploaded, with the result and any change to the plan.
- Reply to the referring GP
- The operation performed, the findings and that care returns to the practice after the two-week review.
When the patient stays in
For an overnight or longer stay, the ward review is dictated at the bedside and drafts into a progress note: observations, the abdomen and wounds, diet and bowels, and the plan. The discharge summary draws on the operation note and each ward note already on the record.
