Kerala Surgical Journal

: 2021  |  Volume : 27  |  Issue : 2  |  Page : 199--201

Documentation in surgical practice

Sanjay Kumar Jain 
 Department of Surgery, Gandhi Medical College and Hamidia Hospital, Bhopal, Madhya Pradesh, India

Correspondence Address:
Dr. Sanjay Kumar Jain
Department of Surgery, Gandhi Medical College and Hamidia Hospital, Royal Market, Bhopal - 462 001, Madhya Pradesh


Documentation and record keeping are the important aspects of health-care practice, and peri-operative practice is no exception to this rule. Recording every activity or intervention that a patient receives is a legal. The clarity of information is essential. Hence, the surgeon has to record appropriate information in the appropriate and meaningful language in a timely manner maintaining confidentiality. Thus, record keeping is a 'part of the professional duty'. In this article, the essential parts of surgical case recording are highlighted.

How to cite this article:
Jain SK. Documentation in surgical practice.Kerala Surg J 2021;27:199-201

How to cite this URL:
Jain SK. Documentation in surgical practice. Kerala Surg J [serial online] 2021 [cited 2022 Aug 9 ];27:199-201
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Modern medical profession is centred on high end superspecialisation and associated with corporate mentality in investigating and treating surgical disease in many private hosptials. This has resulted in the high incidence of legal cases of negligence, not only for the erring doctors but also for the vast majority of ethical doctors, particularly surgeons. Hence, it is high time that all the medcial professionals are conversant with legally valid correct ways of record keeping, so that enquiries conducted by medical specialists will be able to save the ethical doctors from unnecessary and avoidbale litigations. With this idea in mind, I have tried to detail the essential components of proper medical recording with particular emphasis to the surgical management.



The Collins English dictionary (2003) defines documentation as documents supplied as proof of evidence of something'.


Is defined as “a document or other thing that preserves information.”

Surgical documentation

The surgical documentation includes demographics, admission note, pre-operative note, consent, operating notes, post-operative instructions, post-operative notes and discharge notes.


Patient demographics have been classified into following major headings, patient information, patient employer information, physician information and insurance information. Patient information consists of basic demographic information-account no./patient's ID, patient's name, sex, date of birth, marital status, address with PIN no., phone number and copy of ID proof (preferably Aadhar Card).


Consent includes implied consent and informed consent.

Implied consent

Is taken before performing a procedure, it is important to receive consent from the patient, ask permission to make an examination, explain what you intend to do before doing it, ask the patient, if he/she has questions and answer them.

Check that the patient has understood and obtain permission to proceed. Be mindful of the comfort and privacy of others.

Informed consent

Means that the patient and the patient's family understand what is going to take place, including the potential risks and complications of both proceeding and not proceeding and have given permission for a course of action. A quiet venue for discussion should be found written material in the patient's preferred language should be provided to supplement verbal communication, with diagrams where appropriate avoiding complex technical language the provision of translators for the patient do not understand your language. The person obtaining the consent should ideally be the surgeon who will carry out the treatment rather than a junior member of staff. It should be a choice made free from coercion. If a person is too ill to give consent (for example, if unconscious) and their condition will not allow further delay, you should proceed, without formal consent, acting in the best interest of the patient.

If the minor is not capable of giving consent, i.e., does not understand, is incompetent or is unconscious, the parent or guardian may generally provide consent. In adolescent, an ascent should be obtained.

 Operating Notes

An operation note is essential to ensure continuity of care between the operating team and other colleagues and provides a medico legal record of a patient's care. All surgical trainees should know what needs to be detailed in an operation note. Notes must be completed immediately after an operation by a member of the operating team. They can be handwritten or, preferably typed, in line with current guidance from the Royal College of Surgeons of England (RCS). There has been a move towards template-based operation notes to standardize layout and the post-operative instructions, making them easier to understand. The operation note should accompany the patient into recovery and to the ward and should give enough detail to enable continuity of care by another doctor. The operation note can be broken down into the following five main parts. Incision and approach – This should indicate the type of incision or portals used (for example, midline, paramedian and posterior) and approach used. This is particularly helpful should revision surgery be needed. Findings – All operative findings should be documented here, including the pathology encountered, specifying if it was as expected and anatomical variations. Procedure should be a step-by-step account of the operation from incision to closure, starting with any major anatomical structures encountered, then techniques used, tissue excised, prostheses implanted, assisting devices used (image intensifier, gamma probe and tourniquet time), and finally any unexpected complications of the procedure, such as significant blood loss or iatrogenic nerve injury. Closure: This should cover any structures or layers closed in order (fascia, fat and skin) and the method of closure, including the material and technique. The format if the ideal operation note is given in [Table 1].{Table 1}

 Postoperative Instructions

Post-operative instructions are specific instructions to ensure good post-operative care. It is good practice to include things such as venous thromboembolism prophylaxis, samples that have been sent for pathology or microbiology, further antibiotics if required, any instructions to multidisciplinary team members (physiotherapists, for example), specify conditions for discharge in day case procedures. It is important to ensure that any intraoperative images taken are attached to the note (or saved to a picture archiving and communication system, together with a record of serial numbers of prostheses implanted). The document should then be signed, with the signing doctor also documenting his or her name, grade, and General Medical Council number, observation and frequency, possible complications and required actions, specific treatment, for example, intravenous fluids, timeline for normal recovery, when to mobilize, when to resume oral intake, physiotherapy, dressing changes, etc., discharge and follow-up details, instructions for sutures, cast, stents, etc.

 Postoperative Notes

Post-operative notes can be organised in the “SOAP” format, Subjective: How the patient feels, Objective: Findings on physical examination, vital signs and laboratory results, Assessment: What the practitioner thinks and Plan: Management plan, which may also include directives which can be written in a specific location as “orders”.

 Discharge Note

Discharge note is a very important record handed over to the patient ans is the possible source for any initiation of legal action. Hence, this has to be carefully prepared. It should include admitting and definitive diagnoses, summary of patient's course in hospital, instructions about further management as an outpatient, including any medication and the length of administration and follow-up plan.

 Common Errors in Record Keeping

The usual erros seen in record keeping include illegible handwriting, delays in completing the patient record, completed by someone who has not delivered the care, lack of signature, inaccuracies in dates and times, inaccuracies in patient identification information such as wrong date of birth, misspelling of names, inappropriate language, ambiguous abbreviations, opinion mixed with facts and subjective, not objective observations.


This article has attempted to enumerate the simple lessons in proper record keeping when surgeons are needed to take legal precausitons while handling large load of patients in thehopital envioronement so that surgeons can protect themselves from avoidable legal catastrophies.

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Conflicts of interest

There are no conflicts of interest.