This template is designed to record complete and concise surgical notes during rounds before and after the surgery. It includes the patient’s medical history, precautions, diagnostics, and assessments related to their condition. By using this template with Heidi Health’s AI medical scribe, you can:
Focus on examining the patient while generating notes in real-time
Automatically organize important data of the patient, such as their physical examination findings and management
Have a standardized way to communicate with the surgical team regarding the presurgical preparation and postsurgical monitoring plans of the patient
Surgical notes pertain to the documentation done by the surgical team that detail the patient’s progress in the inpatient setting and their ongoing management (not to be mistaken for operative notes, which document everything that transpired during a procedure). Surgical notes are more similar to , only that they’re more specific to the patient’s surgical management before and after the surgery.
Surgical notes often require healthcare providers to scan entire records for necessary information. Surgeons and residents commonly copy and edit previous notes, but this practice can lead to medical errors, such as irrelevant or outdated information. Using a standardized template ensures consistent, direct input of information, making notes easier to understand and reducing clinical errors.
In this article, we’ll discuss how the content of surgical notes differs from operative and medical notes, as well as the importance of creating surgical notes properly. We’ll also talk about the essential parts of surgical notes, how to write them, and free AI-powered templates teams can use to streamline workflows and improve patient care.
Surgical Notes vs Other Relevant Clinical Documentation
While medical and surgical management go hand-in-hand, there are differences between how their respective notes are written. Meanwhile, operative and surgical notes can also be mistaken for one another. In this next section, we’ll discuss the differences across surgical, medical, and operative notes.
Surgical Notes vs Medical Notes
Surgical notes differ from medical SOAP notes in that they are more focused on the patient’s preparations for and recovery from surgery.
Surgical management is more geared towards preventing complications and addressing any issues that may arise. This also includes postsurgical care instructions that need to be continued after discharge and in subsequent follow-up consultations until the patient has fully recovered.
Surgical Notes vs Operative Notes
While surgical notes include details about before and after the surgery, operative notes document what happens during surgery. This includes the anesthetics, medications, and equipment used. Operative notes review each step of the surgical approach used, and they’re used to guide patient care following the procedure.
Why is Surgical Notes Documentation Important?
Thorough and accurate notes for surgery are important because errors may happen at any point in the surgical process. From the presurgical to postsurgical phase of management, many of these errors are not only preventable, but they can also be potentially life-threatening. Here are the top three reasons why high-quality surgical notes are important:
Improve Communication and Facilitate Continuity of Care
All members of the surgical team have to work in tandem with the surgeon to ensure the patient gets the best possible care. However, large teams are prone to miscommunication, even though most correspondence is done through written communication. Common errors include unconventional abbreviations, illegible handwriting, and improper orders.
Due to the highly time-pressured environment in surgery, errors are common, especially in emergent cases. This leaves doctors wanting a way to make surgical notes more efficient, while still retaining all the important information about the patient.
With the help of ambient AI technology, surgical notes can be made significantly faster without sacrificing accuracy. In one trial, the time savings estimated for users reached more than 15,700 hours compared to non-users, over a year of use. AI medical scribes like Heidi make it easier to spell out abbreviations, organize notes, and generate documents for more efficient handovers, improving collaboration across healthcare teams.
Address Legal and Financial Considerations
Properly documenting relevant patient data and management through surgical notes is essential for medicolegal protection, as failing to do so can be considered a breach of providing a standard of care.
Apart from protection from legal repercussions, surgical notes in electronic medical records (EMRs) form the basis for medical coding and billing. In fact, one of the most common causes of inaccurate or inappropriate billing comes from inadequate documentation.
Prevent Inconsistencies and Incomplete Assessments
Another challenge with surgical notes, particularly when care is transferred between medical professionals, is that they can be inconsistent, as clinicians may have different ideas about what patient details are pertinent or not.
On one hand, you want clear and concise one-liners, without leaving anything out. But on the other hand, long and cluttered notes can lead to more sources of error and take more time to read.
The use of surgical notes templates can keep notes consistent between doctors and avoid incomplete assessments. This helps doctors, residents, interns, or even medical students to arrange and extract pertinent information from transcriptions and summarize complex cases.
Similar to the experience of Dr. Richard Bloom, a plastic surgeon. He used to forget to fill in some examination findings, and he’d have to complete them later on. Then, he would ”have to stay back to finish them off or complete them late at night at home.”
But after using Heidi, he reported that he no longer has “any of those issues with filing or not completing notes” anymore. Heidi improved the accuracy of his surgical notes and streamlined his workflow, eliminating the problems of incomplete notes and staying late to finish them.
How to Write Surgical Notes
The first part of a surgical note should include the patient’s identifying information along with the doctors on board for the case such as attendings, residents, and fellows, among others. Note the date and time of assessment, and how many days have passed since the surgery. Next, surgical notes should include the following:
Subjective Findings
Subjective findings should include the overall status of the patient. A reiteration of the patient’s medical history, previous surgeries, social history, and allergies may also be placed here, but they can also be left out if they are already on the admission notes.
Note if the patient is experiencing any symptoms such as postsurgical pain. Ask them if they have already urinated or had any bowel movements since the surgery. Discuss their general feelings after having undergone surgery.
Example note
“Patient was seen back in the room at 10PM after his appendectomy yesterday. He reports currently feeling some abdominal pain and voiced concerns about it. No other subjective complaints. He was reassured that it is normal to feel some pain after the surgery, but advised to watch out for severe pain. He reports no bowel movements since the surgery.”
Physical Exam
The physical exam should include objective findings about vital signs, the general appearance of the patient, and other system findings. The incision site and the surrounding area should be examined for any signs of infection, their drain and urine output noted, and their dressings changed (if necessary).
Example note
“A review of his vital signs shows a heart rate of 90 bpm, blood pressure of 120/80, respiratory rate of 18 cpm, and a temperature of 36.5 degrees Celsius. He was seen awake, responsive to questions, with no signs of distress. On the physical exam, he has normal heart sounds, no additional heart sounds auscultated, clear lungs, and no carotid or abdominal bruits. His surgical wounds on his abdomen are well-coapted and show no sign of infection. Wound dressings were changed.”
Laboratories and Imaging Results
This section includes the summary of the relevant imaging tests, blood chemistry, and clinical microscopy done on the patient. Results of previous laboratories and imaging tests may be reviewed here as well.
Example note:
“His latest chest x-ray shows normal chest findings. His blood chemistry shows slightly elevated WBCs at 12 x 109/L. His electrolytes show no derangements.”
Postsurgical Diagnosis
The diagnosis should include the procedure done and the final diagnosis, following any tests and biopsies done. Postsurgical complications, chronic diseases must be taken into account for any possible complications, and active infections should be mentioned as well.
Example note:
“The postsurgical diagnosis of the patient is s/p Laparoscopic Appendectomy due to Acute Appendicitis, Hypertension, controlled. No complications or infections noted”
Postsurgical Care and Patient Instructions upon Discharge
Lastly, following the surgery, inpatient plans should be stated. From pain management and diet plan to wound care and monitoring, clear instructions should be provided in detail. The level of activity should also be advised to the patient, and referred for physical therapy, if needed.
Once the patient is stable and mostly recovered, discharge planning should be discussed with the team and included in the notes. The usual contents of this section include diet, pain medications, physical therapy, or other referrals, and follow-up periods.
Example note:
“Patient was given Cefazolin 2g IV, as a single presurgical dose for post-surgical prophylaxis. He was advised to continue a bland diet and liquid foods even after discharge. For episodes of pain, the patient was advised to take pain medications (Acetaminophen 500mg and Ibuprofen 200mg ) as needed. The patient was advised to keep their wound dressings dry and clean until they can shower 48 hours after the surgery. Avoid deeply scrubbing or rubbing the wounds, and only use mild soaps to clean the wound area. His next follow-up after discharge will be after a week, with their surgeon.”
Surgical Notes Template Example
Creating surgical notes takes up time and mental effort which could have been spent thoroughly examining patients or helping them understand their management plan. But with the use of Heidi Health’s AI medical scribe, surgeons like Dr. Aman Khanna can save 7-8 minutes per patient consultation and reduce their mental burden to focus on patient care.
Create Faster, Better Surgical Notes with Heidi
With Heidi, clinicians can examine their patients while the AI scribe takes notes in real-time, easing the burden of medical documentation. Here’s how it works:
Transcribe - While going through rounds, simply press “Start transcribing” to have Heidi capture information from the clinical encounter
Customize - After your discussions, choose a template tailored to your needs, so Heidi knows exactly how you like your note
Transform - Heidi can also generate additional documentation from your surgical note, such as an after-visit summary or a referral letter.
There’s no need to worry about data privacy with Heidi, as the AI medical scribe adheres to global patient safety standards (such as HIPAA, GDPR, PIPEDA & APP) and top-notch security certifications such as SOC2 and ISO27001.
This template is used by orthopedic surgeons for their initial evaluation upon patient referral. You can easily dictate your surgical notes to capture detailed assessments, a comprehensive history, and management plans.
This surgical notes template is used by general surgeons to transcribe exchanges during presurgical and postsurgical consultations and outpatient follow-ups. It provides a comprehensive review of the patient’s condition, which includes the patient’s information, their medical history, review of systems, objective findings, impression, and surgical plan.
Initially designed by a urologist, surgeons of other specialties can use this template for inpatient rounds following a surgical procedure. It helps clinicians take note of the events since the last check-up. It also lists any existing and potential medical issues that may occur after the surgery and their treatment approach to each one.
Why does the surgical team have to constantly update the progress of the patient?
Surgical notes should be updated because many changes can happen from the presurgical phase to the diagnosis and plan between admission and the surgery. These can lead to a revised surgical approach or even rule out the possibility of surgery altogether. For example, what was initially a laparoscopic appendectomy can develop into an open procedure if the appendix bursts. After the procedure, monitoring is vital to ensure that there are no postsurgical complications until they’re ready to be sent home.
Can patients request surgical notes from the hospital?
Yes, patients can request surgical notes from their hospital through a formal request. For details regarding the admission details and course in the wards, they’re normally included in the discharge summary already.
What is the best way to make surgical notes?
The best way to make surgical notes is to do them efficiently by gathering as much data as possible with the least amount of time. With an AI medical scribe like Heidi, you can record information step-by-step and have them organized in real time while examining the patient all at once. Since healthcare institutions and individual clinicians have different preferences in making surgical notes, you can easily edit Heidi’s AI-powered templates to fit your organization’s guidelines or your own preferred format.
