1 | Date and time |
2 | Elective/emergency procedure |
3 | The names of the operating surgeon(s) and assistant(s) |
4 | The operative procedure carried out |
5 | The incision |
6 | The operative diagnosis |
7 | The operative findings |
8 | Any problems/complications |
9 | Any extra procedure performed and the reason why it was performed |
10 | Details of tissue removed, added or altered |
11 | Identification of any prosthesis used, including the serial numbers of prostheses and other implanted materials |
12 | Details of closure technique |
13 | Post-operative care instructions |
14 | Signature |