Last updated on Thursday, 15, October, 2026

Operative Note Format: What PHC Indicator 150 Requires

An operative note meets PHC Indicator 150 when the patient’s medical record documents seven things about every operative or other procedure: the name of the service provider or providers, the procedure undertaken, the findings, the estimated blood loss, any specimens removed, any complications during surgery, and the patient’s condition at the conclusion of the surgery or procedure.

This guide explains each of the seven contents, shows where hospitals usually slip, and gives you a template your surgical teams can start using this week.

Regulator	Punjab Healthcare Commission (PHC)
Standard	29 (IMS-2): the medical record reflects continuity of care
Indicator	150
Priority	Critical
Applies to	Hospitals performing operations and other procedures

Indicator 150 is part of the PHC Information Management Systems standards. For all 19 indicators, see our guide to PHC Information Management Standards (IMS 28-30).

What PHC Indicator 150 Requires

The indicator says operative and other procedures performed are incorporated in the medical record. A reviewer checking a patient’s file looks for two things:

1. The procedure is documented in the record. If an operation or procedure happened, the file must show it.
2. The documentation covers the seven required items. Missing even one, such as estimated blood loss, leaves the record incomplete.

Note the words “and other procedures”. The indicator is not limited to major operations in the theatre. Decide in your hospital policy which procedures need a full operative note, and make sure the rest are still recorded with the same seven items.

Why It Is a Critical Indicator

Indicator 150 is one of six critical indicators in Standard 29, alongside admission and diagnosis (149), transfers (151), discharge (152), death (153) and autopsy (154). An operation is one of the highest-risk events in a patient’s stay, and the operative note is the main written account of what was done, found and removed. If it is incomplete, the next doctor, the patient and the hospital all carry the risk.

The 7 Contents an Operative Note Must Include

The PHC lists these seven as the minimum. The “what to write” column is practical guidance for surgical teams; the seven headings are the PHC’s.

#	PHC requirement	What to write	Example entry
1	Name of the service provider(s)	Surgeon, assistants, anaesthetist and any other provider involved, with titles	Surgeon: Dr A (consultant surgeon); assistant: Dr B; anaesthetist: Dr C
2	Procedure undertaken	The exact name of the procedure, plus its date and start and end time	Laparoscopic appendectomy, 11 Oct, 09:15 to 10:05
3	Findings	What was seen and found during the procedure	Inflamed, non-perforated appendix; no free fluid
4	Estimated blood loss	A figure in ml, or an explicit “minimal” or “nil”	About 30 ml
5	Any specimens removed	What was removed and where it was sent, or “none”	Appendix sent for histopathology
6	Complications during surgery	Any complication and how it was handled, or “none”	None
7	Patient’s condition at the conclusion of the surgery or procedure	Status when the procedure ended and where the patient went next	Stable; transferred to recovery

The examples are illustrative only. Use your own clinical content.

Write “none” instead of leaving a field blank. For blood loss, specimens and complications, a blank looks like an omission. An explicit “none” or “minimal” shows the item was considered.

Many hospitals add more. Pre- and post-operative diagnosis, anaesthesia type, implants used and instrument or swab counts are common extras. They are good practice, but they are not among the seven the PHC lists, so add them on top, never instead.

Where Hospitals Usually Fail on Operative Records

These are the gaps to look for in your own files. Each maps directly to the indicator’s wording.

• Estimated blood loss left out. It is easy to forget when the case is routine.
• Specimens not recorded, or recorded without saying where they were sent.
• “No complications” never written. Silence is not a record.
• Provider names missing, or only the surgeon named and the assistants and anaesthetist left out.
• No statement of the patient’s condition at the end of the procedure.
• Note written late, or never, because it was left until after the list finished.
• No name, title, date or time with the signature. Like every entry, an operative note should show who wrote it and when (Indicators 146 and 147).
• Minor procedures not recorded because they were not treated as operations.
• Illegible handwriting, which fails a legibility review (Indicator 159).

If your theatres show more than a few of these, a monthly sample audit will show how widespread the problem is. 

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How to Comply with Indicator 150 in Six Steps

1. Define which procedures need a full note. List them in your policy, and say that every other procedure still needs the seven items.
2. Decide who writes the note. Usually the operating surgeon. Add those roles to your written list of authorized individuals (Indicator 145).
3. Use one standard form built around the seven headings, so no theatre invents its own format.
4. Complete it straight after the procedure, before the next case starts, while details are fresh.
5. Sign it properly. The author adds name, title, date and time. Corrections follow the PHC rule: a separate dated, timed and signed line, never a cross-out (Indicator 161).
6. Audit a sample every month. Check that all seven items are present in recent operative notes, and document what you find and fix (Indicators 156 to 162).

Operative Note Template

Use this as a starting point and adapt the wording to your theatres.

Section	Entry
Patient (name, age, sex, MRN)
1. Service provider(s): surgeon, assistants, anaesthetist
2. Procedure undertaken, date, start and end time
3. Findings
4. Estimated blood loss
5. Specimens removed (and where sent), or “none”
6. Complications during surgery, or “none”
7. Patient’s condition at the end of the procedure
Written by (name and title)
Signature, date and time

How Hospital Management Software Helps with Operative Records

Paper operative notes get lost between theatre and ward, written late, or left with a field blank. A hospital management system closes those gaps.

With CoreMedix hospital management software from InstaCare, the operative note is built inside the patient’s record, so:

• The note follows the seven required headings, so none is forgotten.
• Required fields can be made mandatory before the note is finalized, which stops a blank blood-loss or specimens field.
• Each entry carries the author’s name, title, date and time automatically.
• The note sits in the same record as the admission note and the discharge summary, so the next doctor sees the whole story.
• Your quality team can pull recent operative notes for a monthly audit instead of searching paper files.

Want to see it working on your own theatre records? Request a demo.

Prepare Your Hospital for PHC Review

• Download the PHC IMS checklist: all 19 indicators, color-coded critical and non-critical.
• Request a demo to see how CoreMedix handles operative notes and the rest of the medical record.

Frequently Asked Questions

What Does PHC Indicator 150 Require?

Operative and other procedures performed must be incorporated in the medical record, with documentation of seven items: provider names, procedure undertaken, findings, estimated blood loss, specimens removed, complications and the patient’s condition at the end.

Is Indicator 150 Critical?

Yes. The PHC marks it as a critical indicator under Standard 29 (IMS-2).

What Must an Operative Note Include?

The name of the service provider(s), the procedure undertaken, the findings, estimated blood loss, any specimens removed, complications during surgery, and the patient’s condition at the conclusion of the surgery or procedure.

Does Indicator 150 Cover Minor Procedures?

The indicator refers to operative and other procedures performed, so it is not limited to major surgery. Set a policy for which procedures need a full operative note, and record the seven items for any procedure you perform.

Who Should Write the Operative Note?

A person on your written list of authorized individuals, usually the operating surgeon. The entry must show the author’s name and title, with date and time.

How Can We Check That Our Operative Notes Comply?

Review a sample of recent procedure records each month and check that all seven items are present and legible. Record the gaps and the corrective action taken.