• Muhammad Umar Younis Mediclinic City Hospital Dubai Mohammed Bin Rashid University of Medicine and Health Sciences


Background: Operative notes are the most important account of a surgical procedure containing all details that may have been encountered during the surgery. Summary: Below par quality of these notes remains a challenge for the healthcare system and guidelines from the Royal College of Surgeons should be made use of to ensure efficient recording. Operative notes need to be legible with clear and concise instructions for the nursing staff for postoperative care. Key messages: Relevant details of surgery, additional procedures and complications should be thoroughly documented as well to avoid losses in terms of financial remuneration and for medicolegal purposes. Residents in training should be taught about their importance and inclusion in surgical curriculum should be sought. Keywords: Documentation; Guidance; Note writing; Operation note; Surgery

Author Biography

Muhammad Umar Younis, Mediclinic City Hospital Dubai Mohammed Bin Rashid University of Medicine and Health Sciences



Severn Audit and Research Collaborative in Orthopaedics (SARCO), Blackburn J. Assessing the quality of operation notes: a review of 1092 operation notes in 9 UK hospitals. Patient Saf Surg 2016;10:5.

Hossain T, Hossain N. Guidance on writing general surgical operation notes: a review of the literature. Int Surg J 2015;2(3):326–30.

Park J, Pillarisetty VG, Brennan MF, Jarnagin WR, D’Angelica MI, DeMatteo RP, et al. Electronic synoptic operative reporting: assessing the reliability and completeness of synoptic reports for pancreatic resection. J Am Coll Surg 2010;211(3):308–15.

General Medical Council. The duties of a doctor registered with the General Medical Council. Good medical practice guideline booklet. 3rd ed. London, UK. 2001.

The Royal College of Surgeons of England. Guidelines for clinicians on medical records and notes. Royal College of Surgeons of England; 1994.

The Royal College of Surgeons of England. Good surgical practice, 2014. [Internet]. Surgeons of England 35-43 Lincoln’s Inn Fields London [cited 2020 April]. Available from:

Ma GW, Pooni A, Forbes SS, Eskicioglu C, Pearsall E, Brenneman FD, et al. Quality of Inguinal Hernia Operative Reports: Room for Improvement. Can J Surg 2013;56(6):393–7.

Dukic I, Shaw G, Dukic M, Hussain M, Al-Buheissi S, Maraj B. A comparison of handwritten to computerised urological operative notes. Br J Med Surg Urol 2010;3(1):22–4.

Din R, Jena D, Muddu BN, Jena D. The use of an aide-memoire to improve the quality of operation notes in an orthopaedic unit. Ann R Coll Surg Engl 2001;83(5):319–20.

Mehtab H, Waqar SH, Abdullah MT, Khaliq T. Quality of Operation Notes in General Surgery: A Teaching Institute Experience. Ann Pak Inst Med Sci 2017;13(3):222–5.

Wiebe ME, Sandhu L, Takata JL, Kennedy ED, Baxter NN, Gagliardi AR, et al. Quality of narrative operative reports in pancreatic surgery. Can J Surg 2013;56(5):121–7.

O’Bichere A, Sellu D. The quality of operation notes: can simple word processors help? Ann Royal Coll Surg Engl 1997;79(5 Suppl):204–9.

Shaikh FA, Alvi AR, Shahzad N, Gala T, Murtaza G. Template operative note, a better documentation. J Pak Med Assoc 2019;69(3):409–11.

Dukic I, Vissamsetti B, Payne S. “Improving the quality of operation notes.” BJU Int 2011;107(10):1546–8.

Gur I, Gur D, Recabaren JA. The Computerized Synoptic Operative Report: A Novel Tool in Surgical Residency Education. Arch Surg 2012;147(1):71–4.

Ghani Y, Thakrar R, Kosuge D, Bates P. ‘Smart’ electronic operation notes in surgery: an innovative way to improve patient care. Int J Surg 2014;12(5):30–2.

WHO, WHO Patient Safety. Implementation manual: WHO surgical safety checklist (‎first edition)‎. [Internet]. World Health Organization, WHO Patient Safety. 2008 [cited 2020 April]; Available from:

Joint Commission International. International Patient Safety Goals 2017. [Internet]. [cited 2017 July 15]. Available from:

Vickers R. five steps to safer surgery. Ann R Coll Surg Engl 2011;93(7):501–3.

Flynn MB, Allen DA. The operative note as billing documentation: a preliminary report. Am Surg 2004;70(7):570–5.

Johari A, Zaidi NH, Bokhari RF, Altaf A. Effectiveness of teaching operation notes to surgical residents. Saudi Surg J 2013;1(1):8.

Eryigit O, van de Graaf FW, Lange JF. A systematic review on the synoptic operative report versus the narrative operative report in surgery. World J Surg 2019;43(9):2175–85.

Stogryn S, Hardy KM, Abou-Setta AM, Clouston KM, Metcalfe J, et al. Advancement in the quality of operative documentation: a systematic review and meta-analysis of synoptic versus narrative operative reporting. Am J Surg 2019;218(3):624–30.

Liu C, Cheifetz R, Brown C, Nichol A, Speers C, Lohrisch C, et al. Do surgeons convey all the details? A provincial assessment of operative reporting for breast cancer. Am J Surg 2020;219(5):780–4.

Stogryn SE, Hardy K, Mullan MJ, Park J, Andrew C, Vergis A. Synoptic operative reporting: assessing the completeness, accuracy, reliability, and efficiency of synoptic reporting for Roux-en-Y gastric bypass. Surg Endosc 2018;32(4):1729–39.

Bidwell SS, Merrell SB, Poles G, Morris AM. Implementation of a Synoptic Operative Report for Rectal Cancer. Dis Colon Rectum 2020;63(2):190–9.

Novitsky YW, Sing RF, Kercher KW, Griffo ML, Matthews BD, Heniford BT. Prospective, blinded evaluation of accuracy of operative reports dictated by surgical residents. Am Surg 2005;71(8):627–31.

Dumitra S, Wong SM, Meterissian S, Featherstone R, Barkun J, Fata P. The operative dictation: a review of how this skill is taught and assessed in surgical residency programs. J Surg Educ 2015;72(2):321–9.

Hyde GA, Biderman MD, Nelson EC. Resident operative reports before and after structured education. Am Surg 2018;84(6):987–90.