Operative Note – Standard Surgical Procedure

Operative Note – Standard Surgical Procedure Procedure Name and Indication: [document the official name of the procedure performed, including indication and anatomical site. Include clinical context relevant to the South African setting, such as surgery for complications of TB, trauma, malignancy, or obstetric emergencies] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Date, Team, and Anaesthesia: [include the date of operation in DD/MM/YYYY format, names of primary and assistant surgeons, anaesthetist, and type of anaesthesia (e.g. general, spinal, regional block). Mention if performed in a district, regional, or tertiary hospital setting] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Patient Positioning and Site Preparation: [describe patient positioning (e.g. supine, lateral, lithotomy), antiseptic prep (e.g. chlorhexidine, iodine), and whether site was marked pre-operatively as per local theatre protocol] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Surgical Steps and Intraoperative Details: [provide sequence of steps taken during the procedure, instruments or implants used, anatomical structures encountered, and any deviation from standard technique. Include use of surgical kits commonly available in state hospitals or if any specialised equipment was required in the private sector] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Findings and Key Observations: [note any abnormal or unexpected anatomical/pathological findings, such as abscesses, adhesions, perforation, tumour spread, necrosis, or anatomical variants encountered during the procedure] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Complications and Intraoperative Management: [include any intraoperative complications such as bleeding, injury to bowel, bladder, or major vessels, anaesthetic complications, or need for conversion/escalation. Document intraoperative actions taken to manage complications] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Closure and Postoperative Plan: [detail method of wound closure (e.g. interrupted sutures with nylon, subcuticular Vicryl), placement of drains, dressings applied, and post-op care instructions including analgesia, antibiotics, early mobilisation, or ward transfer. Note if the patient was transferred to ICU or general ward, and if post-op review was arranged] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs, or bullet points as needed to capture all the relevant information from the transcript.)