Why Surgical Documentation is Uniquely Challenging Surgical cases demand three distinct documentation moments: pre-operative assessment (why surgery is needed, patient risk factors, informed consent), intra-operative findings (what you found, what you did, any deviations from plan), and post-operative status (complications, discharge instructions, follow-up timeline). Traditional method—handwritten intra-op notes that are illegible, post-op summary that gets typed hours later, recovery room notes scattered across multiple pages—creates fragmented records that lack continuity.
Moreover, surgical notes must be legally precise: they document consent, critical decision-making, and specific techniques. A blurry record isn't just clinically problematic; it's a liability risk. PawfectNotes captures your real-time intra-operative narration and produces a comprehensive operative report that leaves no question about what happened.
Example Veterinary Surgery SOAP Note Sample note
Patient: Buddy, 5-year-old Labrador Retriever, 28 kg, male, neutered
Presenting Complaint: Right hindlimb lameness; cranial cruciate ligament rupture; scheduled for TPLO (Tibial Plateau Leveling Osteotomy)
SUBJECTIVE:
OBJECTIVE - PRE-OPERATIVE:
Vitals (Pre-Operative Exam):
Temperature: 37.9°C Heart Rate: 76 bpm Respiratory Rate: 18/min Blood Pressure: 118/74 mmHg
Body Weight: 28 kg Body Condition Score: 6/9 Physical Examination (Pre-Op):
General: Alert, normal mentation, no distress Orthopedic exam: Right hindlimb with grade 2/5 lameness; positive cranial drawer test on right stifle (moderate laxity); positive tibial compression test; pain elicited on stifle manipulation; left hindlimb normal, negative drawer test
Radiographs (previous, reviewed in chart): Right stifle effusion and mild periarticular osteophytes, consistent with cranial cruciate ligament rupture; tibial plateau angle (TPA) measured at 28 degrees
Pre-operative laboratory: CBC and chemistry within normal limits; PT/PTT normal; no contraindications to anesthesia
Pre-Operative Checklist:
Informed consent obtained from owner; TPLO procedure discussed including expected recovery (8-12 weeks), restricted activity requirements, cost estimate, and potential complications (infection, implant failure, stifle arthritis)
Pre-operative antibiotics administered: Cefazolin 20 mg/kg IV (560 mg) Pre-operative analgesia: Hydromorphone 0.1 mg/kg IV (2.8 mg); carprofen 2.2 mg/kg SC (61.6 mg)
INTRA-OPERATIVE FINDINGS & PROCEDURE:
Anesthesia Induction & Maintenance:
Pre-medication: Dexmedetomidine 0.003 mg/kg IV (0.08 mg), given with the hydromorphone above
Induction: Propofol 4 mg/kg IV (112 mg) over 60 seconds; smooth induction, no complications
Intubation: 7.5 mm endotracheal tube placed successfully, cuff inflated to pressure Maintenance: Isoflurane inhaled anesthetic, oxygen 2-3 L/min throughout; ETCO2 maintained 35-45 mmHg; blood pressure remained 95-115 systolic throughout
Surgical Preparation:
Patient positioned in dorsal recumbency, right hindlimb raised and abducted
Right hindlimb clipped from mid-femur to mid-metatarsus in wide sterile field Surgical site (right stifle) scrubbed with 4% chlorhexidine, rinsed with 70% isopropyl alcohol, repeated × 2, dried with sterile towels
Sterile draping applied; surgical field isolated Surgical Approach:
Medial approach to the right stifle and proximal tibia Skin incision along the medial aspect of the stifle, extending distally over the proximal tibia
Medial parapatellar mini-arthrotomy performed to inspect the joint Joint fluid aspirated (approximately 2 mL clear synovial fluid) and submitted for synovial fluid analysis (sterile technique); fluid clear, no blood, no debris
Joint Examination & Intra-Operative Findings:
Cranial cruciate ligament thoroughly disrupted; remnants debrided; confirmed complete CCL rupture
Menisci visualized: Medial meniscus intact, normal appearance; lateral meniscus intact, normal appearance; no meniscal damage
Cartilage surfaces: Femoral condyles appear smooth, normal; tibial plateau smooth; no cartilage lesions or fibrillation; minimal early degenerative changes consistent with pre-operative radiographs
Caudal capsule intact; joint appears otherwise normal No loose bodies; mild synovitis
TPLO Procedure - Execution:
TPLO plate (3.5 mm, 6-hole, stainless steel locking plate) pre-selected and confirmed appropriate size for tibia
Medial cortex of the proximal tibia exposed; jig placed Radial osteotomy planned with a biradial saw to reduce tibial plateau angle from approximately 28 degrees to approximately 5 degrees
Osteotomy executed with biradial saw, centered on the intercondylar eminence, preserving the tibial tuberosity and patellar ligament insertion; complete cut confirmed, proximal tibial segment fully mobile
Rotation of proximal tibial segment performed per pre-operative chart (approximately 8 mm along the osteotomy), achieving a TPA of approximately 5 degrees; surgical outcome matches pre-operative plan
Plate positioning: TPLO plate placed on medial cortex of tibia, bridging osteotomy site Screw placement: Three 3.5 mm locking screws proximal and three distal to the osteotomy, all bicortical and fully seated
Post-fixation radiographic confirmation (intra-operative fluoroscopy, craniocaudal and mediolateral views): appropriate plate positioning, screw placement, and osteotomy reduction; no intra-articular screw placement; no varus/valgus deformity; alignment excellent
Intra-Operative Irrigation & Closure:
Joint irrigated copiously with warm sterile saline; all debris removed, joint cleared
Joint capsule closed with 2-0 absorbable suture (polydioxanone); simple interrupted pattern; capsule edges well-approximated
Fascial layers closed over the plate with 2-0 polydioxanone, simple continuous pattern; hemostasis maintained
Subcutaneous tissue approximated with 3-0 poliglecaprone 25, simple continuous pattern Skin closed with 3-0 non-absorbable monofilament suture (nylon), simple interrupted pattern; even spacing, minimal tension, no gaps
Surgical site inspected for hemostasis; minimal oozing controlled; final site dry Dressing applied: Sterile adhesive dressing over incision; light padded bandage for the first 24 hours
Intra-Operative Anesthesia Management:
Anesthesia remained stable throughout 45-minute surgical time
Blood pressure maintained 95-115 systolic; heart rate 65-85 bpm; SpO2 maintained >95% throughout
IV fluids: Balanced crystalloid (LRS) administered at 5 mL/kg/hr throughout Intra-operative analgesia: Fentanyl 2 mcg/kg IV bolus (56 mcg) administered at start of procedure; epidural analgesia not utilized for this case
Post-Operative Anesthesia Recovery:
Anesthetic agents discontinued at end of procedure
Isoflurane weaned off; oxygen continued for 5 minutes post-anesthetic Patient recovered smoothly with normal extubation (cuff deflated, tube removed when swallow reflex returned)
Recovery uneventful; patient quiet and calm in recovery cage No straining, no vocalization, no complications noted
OBJECTIVE - POST-OPERATIVE:
Immediate Post-Operative Assessment (30 minutes post-op):
Vitals: Temperature 37.2°C, HR 68 bpm, RR 16/min, conscious and alert Hindlimb: Bandage intact, no bleeding through dressing, swelling minimal
Pain assessment: Patient resting quietly; minimal response to limb palpation; pain level appears controlled
Hydration: Mucous membranes pink, CRT <1 second Discharge Instructions Provided (Owner Counseling):
Activity restriction: Strict kennel rest/crate confinement for 8 weeks; leash walks only (5-10 minute walks, 2-3 times daily) for bathroom breaks; NO free play, NO jumping, NO running
Bandage care: Padded bandage removed before discharge; keep incision clean and covered as instructed; watch for signs of infection (drainage, odor, heat)
Pain management: Continue carprofen 2.2 mg/kg PO BID for 10 days; gabapentin 10 mg/kg PO BID-TID as needed for additional pain control
Wound care: No soaking or swimming until sutures removed at 10-14 days; keep wound clean and dry; inspect daily for signs of infection
Suture removal: Scheduled in 10-14 days with technician for wound assessment ASSESSMENT:
Right cranial cruciate ligament rupture—COMPLETE, confirmed intra-operatively TPLO surgery completed successfully; tibial plateau angle reduced from approximately 28 degrees to approximately 5 degrees
Appropriate plate positioning and screw fixation confirmed with intra-operative fluoroscopy
No meniscal injury identified No cartilage lesions beyond early degenerative changes
Anesthesia and surgical recovery uneventful; no intra-operative complications Post-operative pain controlled with current regimen
Prognosis: Excellent for return to function with appropriate post-operative rehabilitation
PLAN:
Post-Operative Analgesia (In-Hospital):
Hydromorphone 0.1 mg/kg IV q4-6h overnight, guided by pain scoring Discharge next day on oral medication: Carprofen 2.2 mg/kg PO BID for 10 days; gabapentin 10 mg/kg PO BID-TID as needed
Phone check in 3 days; additional analgesia if needed Antibiotic Prophylaxis:
Cefazolin 20 mg/kg IV given pre-operatively (single peri-operative dose; surgical time under 90 minutes)
Discharge home without continued systemic antibiotics (prophylactic use only) Post-Operative Rehabilitation:
Activity restriction (strict kennel rest) for 8 weeks Physical therapy protocol starting week 3: Passive range of motion, gentle weight-bearing exercises, graduated activity increase
Hydrotherapy may be considered week 4-6 if available (non-weight bearing initially) Return to normal activity: Gradual over weeks 8-12, once radiographs confirm healing
Monitoring & Follow-Up:
Suture removal: 10-14 days post-op with technician; wound assessment at removal
Re-check examination and radiographs at 8 weeks: Assess gait, limb use, pain, and healing of the osteotomy
Return to unrestricted activity: Typically 12 weeks post-op if healing on track and patient is sound
Complications Monitoring:
Watch for: Increased swelling, drainage, heat at incision site (infection risk)
Watch for: Patient inability to bear weight at 3 weeks (may indicate plate complications or pain inadequately controlled)
Watch for: Fever (possible infection); contact clinic immediately if temperature >39.5°C Watch for: Lameness worsening rather than improving by week 4 (may indicate implant failure or other complication)
Owner Communication:
Emphasized importance of strict activity restriction; many failures result from premature activity
Discussed that recovery is 8-12 weeks; prognosis for return to normal function is excellent (>90% success rate with compliance)
Provided written discharge instructions including warning signs for infection Scheduled suture removal appointment before discharge; provided technician contact number for questions
How PawfectNotes Handles Surgical Terminology Surgical documentation requires precision in operative technique description, anatomy, and temporal sequencing. PawfectNotes excels at capturing this detail.
Operative Approach & Technique Language:
You say: "Medial parapatellar approach, cranial capsulotomy, TPLO guide positioning medial to tibial crest"
PawfectNotes captures: Maintains precise anatomical approach terminology, preserves procedural sequence
Intra-Operative Findings & Assessment:
You say: "Complete CCL rupture, ligament remnants debrided; menisci intact, no cartilage lesions beyond early OA changes"
PawfectNotes captures: Distinguishes findings by anatomic structure, maintains injury severity language
Implant Placement & Measurements:
You say: "Six-hole TPLO plate, tibial plateau angle reduced from 28 to 5 degrees, plate positioned medial cortex with bicortical screw fixation"
PawfectNotes captures: Preserves implant specifications, maintains angle measurements, captures fixation technique
Intra-Operative Monitoring & Hemostasis:
You say: "BP maintained 95 to 115 systolic throughout, SpO2 >95%, minimal intra-operative bleeding controlled with cautery and saline irrigation"
PawfectNotes captures: Maintains vital sign parameters, hemostasis technique, anesthetic stability notations
Customizing Your Templates for Veterinary Surgery Surgical practices demand templates organized by procedure type, with clear pre-op, intra-op, and post-op sections.
Setting Objective Normals:
Building Procedure-Specific Templates:
Intra-Op Voice Capture:
Try PawfectNotes on Your Next Surgery Surgical cases demand documentation that's legally precise and clinically complete.
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