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General Principles Date and time, elective or emergency procedure. Names of operating surgeon, surgical assistant, and anaesthetist. Name of the operative procedure, with the incision made. The operative diagnosis and the findings. Complications and any additional procedures performed (and why)
Box: What to include in an operation note, from Good Surgical Practice 2014 Date and time. Elective or emergency procedure. Names of operating surgeon and assistant. Name of anaesthetist. Operative procedure. Incision. Operative diagnosis. Findings.
I have been explained and have understood that the proposed treatment / procedure / surgery has high rate of relapse and recurrence. 13. I have been explained and have understood that the proposed treatment / procedure / surgery generally require multiple sessions / sittings and I give my consent for the same.
1) I have read and understood the information contained here; 2) I have been informed about the Procedure and the potential risks, benefits, alternatives and the risk of those alternatives; 3) I authorize and consent to the performance of the Procedure as described; and 4) I authorize and direct that any Specimen ...
Operative notes are traditionally created at the completion of a surgical procedure by the primary surgeon who recalls the procedure details and dictates these into a narrative that is subsequently transcribed.