Table 1. Checklist of essential parameters for surgical operation notes.

This checklist was developed in accordance with the documentation standards set by the Royal College of Surgeons (RCS) of England. It includes the core parameters recommended for high-quality operative note writing, ensuring completeness, clarity, and medicolegal reliability. The checklist was used to evaluate the quality and completeness of surgical notes during the audit cycles. Record Your Work Clearly, Accurately, and Legibly (2024) [8].

LMWH: low molecular weight heparin; DVT: deep vein thrombosis

Parameters	Description
Date and time	Record the exact date and time of the procedure.
Type of operation	Specify the procedure performed (e.g., appendectomy).
Name of operator and assistant	Include full names of the lead surgeon and assisting staff.
Name of anesthetist	Document the anesthetist responsible for the case.
Operative procedure carried out	Describe the procedure actually performed, including modifications, if any.
Incision type	State the location and type of incision made.
Operative diagnosis	Provide the final intraoperative diagnosis.
Operative findings	Note key intraoperative findings including pathology and anatomical details.
Problems/complications	Mention any intraoperative issues or complications encountered.
Any extra procedures and why performed	Detail any additional procedures done and the reasons for them.
Details of tissue removed, added, or altered	Describe any excised or grafted tissues and anatomical alterations.
Identification of prostheses/material used	Provide details of any implants or foreign materials (e.g., mesh, plates).
Details of closure technique	Describe how the wound was closed (e.g., sutures, staples, layers).
Anticipated blood loss	Estimate the amount of blood lost during the procedure.
Prophylactic antibiotics	Record type, dose, and timing of antibiotics given pre-/intraoperatively.
Deep vein thrombosis (DVT) prophylaxis	State whether DVT prophylaxis was used and its form (e.g., LMWH, compression).
Postoperative care instructions	Include postoperative orders, follow-up, and any specific care instructions.
Surgeon’s signature	Surgeon must sign the note to validate the documentation.