Operative Report

Operative Report Components

Following are the key components to an operative report*:

  • Facility where study was performed
  • Patient identifying information (name + another identifier)
  • Procedure date
  • Preoperative diagnosis
  • Postoperative diagnosis
  • Procedure
  • Dictating physician
  • Surgeon(s)
  • Assistants
  • Anesthesiologist
  • Anesthetic
  • Patient history & clinical justification for procedure (indications)
  • Operations performed
  • Specimens removed (e.g., organs & tissue)
  • Pathological findings (e.g., intraoperative frozen section assessment of margins in pathology)
  • Complications
  • Estimated blood loss (EBL)
  • Fluids received
  • Findings
  • Chronological details of procedure including whether & what tissue was sent to pathology
  • Findings
  • Postoperative course
  • Disposition (discharge information & follow up instructions)

* Note that the order & presentation of these components may vary across hospitals


Common components in ovarian cancer staging operation reports

  • Evaluation of the undersurface of the diaphragm
  • Appearance of both ovaries
  • Whether the ovarian capsule was ruptured before or during the procedure
  • Extent of involvement of other abdominal organs (adnexa, pelvic wall, pelvic tissues)
  • Seeding & tumor implants
  • Encasement, nodularity of viscera
  • Frozen pelvis
  • Biopsies & intraoperative frozen section diagnoses of:
    • Pelvic & abdominal peritoneum
    • Pelvic & paraaortic lymph nodes
    • Any suspicious nodules or masses
  • Tumor on or in the liver that is not biopsied
  • Nodules or evidence of tumor on the diaphragm that is not biopsied
  • Amount of tumor not resected (to estimate residual tumor bulk)
  • Areas where tumor was not removed
  • Peritoneal washings

Updated: June 8, 2018