How to keep surgical case notes

1. General info

Describe the operation in a line or two, with any other names you hear for the operation.

2. Indications

List when the operation is chosen, when the operation is avoided, what else is offered, and what to review beforehand.

Residents who talked the case over with the attending before the day of surgery had twice the odds of rating their role as more active (Bailey 2018). The survey shows a link, not a cause.

3. Relevant anatomy

Note the landmarks you use and the structures to protect at each stage.

Watching a procedure video beforehand improved residents' performance in the real operating room, in a randomized trial of laparoscopic right colectomy (Crawshaw 2016). Rehearsing one patient's own anatomy helped with anatomical variants in a small trial (Yiasemidou 2018). Neurosurgeons most often recommend Rhoton's cranial anatomy text, and the Neurosurgical Atlas was their second most-used online resource (Hoz 2021).

4. Equipment and set-up

Record the position, room layout, equipment, implants, and imaging to have ready.

Residents feel least prepared on choosing instruments and sutures (Pugh 2010). In one otolaryngology pilot, residents lagged on recognizing specific instruments and asked to be taught set-up (Yam 2023). Preference cards are often out of date, and 46% of surgeons in one survey rarely or never updated theirs (Palmisano 2024).

5. Steps

List the steps in order and the decision at each one.

Breaking a procedure into steps, decision points, and common errors improved novices' performance, mostly in simulation (Edwards 2021). In one simulated hip replacement trial, trainees taught this way were 35% faster and made 69% fewer instrument-selection errors (Logishetty 2020). Mental rehearsal helps as an add-on for trainees with some experience, though pooled results are mixed (Rao 2015; Lin 2020; Arora 2011).

6. Complications

List each complication, how you would notice one, what to do first, and who to call.

Experts rehearse troubleshooting and team communication, while novices focus on history and anatomy (Ghaderi 2021).

7. Attending preferences

Add what each attending does differently here, one attending at a time.

Surgeons' preferences vary. Residents learn to separate principle from preference, and the variation itself teaches (Apramian 2015; Apramian 2016).

8. Pearls

Keep short lessons worth rereading the night before, one per line.

Testing yourself beats rereading for long-term retention (Green 2018). In one trial, scores at six months were 39% after repeated testing and 26% after repeated study (Larsen 2009). Spaced study helps too, though the best interval is unknown, and one large trial saw no gain on the in-service exam (Cecilio-Fernandes 2018; Kerfoot 2007).

9. Operative note templates

Keep a dictation outline, with *** wherever a case detail goes.

Structured operative reports are more complete and quicker to write. Narrative reports keep more procedure-specific detail, so a hybrid makes sense (Stogryn 2019; Eryigit 2019). Dictation is rarely taught, and a short session or a checklist card raised note quality in small studies (Dumitra 2015; Eichholz 2004; Hyde 2018). A template helped junior residents' operative notes and their comfort, though not overall quality, in a small trial (Gillman 2010).

10. Reflections, research, and improvements

After a case, write what you expected, what happened, and what to change next time.

Debriefing after a task improves performance by about a quarter on average, mostly in studies of teams outside surgery (Tannenbaum 2013). Coaching with video review and debriefing improves trainees' skill (Bonrath 2015; Augestad 2020). Evidence for reflection on its own is largely theoretical, so take this section to a debrief with your attending (Mann 2009).

Bring the notes you already keep

Notes in Apple Notes export as Markdown, and Capnolog opens the Markdown file. Importing your notes is free.