Template operative note, a better documentation

Fareed Ahmed Shaikh, Abdul Rehman Alvi, Noman Shahzad, Tanzeela Gala, Ghulam Murtaza

Research output: Contribution to journalArticlepeer-review

4 Citations (Scopus)


Operative notes are a valuable part of patient's medical record, and carry the medico-legal significance. One way of improving it is to introduce the template form operative notes. Only few studies have been done worldwide to compare both the forms of operative notes. This cross-sectional study was conducted in the department of General Surgery, AKUH. This included the patients who underwent Laparoscopic cholecystectomy (Complying with inclusion criteria) from August 2013 till March 2014. Out of 24 patients, 19 were females. The completeness of data in template group was significantly better than traditional group (79.2% vs. 8.3%). There was no significant difference among the residents of different level (writing the notes) and the completeness of data in both the groups. Similarly the timing of day did not affect significantly on the completeness.

Original languageEnglish
Pages (from-to)409-411
Number of pages3
JournalJPMA. The Journal of the Pakistan Medical Association
Issue number3
Publication statusPublished - 1 Mar 2019


  • Template operative notes, Laparoscopic cholecystectomy, Completeness of data.


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