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Dictate the operation once. The note comes back in the record's sections.

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Verbato writes an operative note from your dictation.

For surgeons who dictate the operation at the end of surgery.

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What is an operative report?

An operative note, or operative report, is the surgeon's written account of an operation: the diagnoses before and after it, what was done and found, the technique step by step, and any complications.

In practice

The operative note travels with the patient. The Royal College of Surgeons of England asks for clear, preferably typed notes for every procedure, which go with the patient into recovery and to the ward and give enough detail for another doctor to continue care. Besides the procedure, the operative diagnosis and the findings, it asks for any extra procedure and why it was done, the tissue removed, added or altered, the serial numbers of any prosthesis or implant, the closure technique, the estimated blood loss, antibiotic and thrombosis prophylaxis where they apply, and detailed postoperative care instructions (RCS England, 2025).

Further reading: The Royal College of Radiologists' standards for reporting imaging; Weed (1968), on the problem-oriented record the SOAP note comes from

What you say, and the operative note you get back

Illustrative example

The transcript excerpt and the document are written to show the format. Every name, figure and quote is invented.

What you say · transcript excerpt

operative note for bed fourteen ruth alvarez forty six years old period preoperative diagnosis symptomatic cholelithiasis period postoperative diagnosis same period procedure performed laparoscopic cholecystectomy with intraoperative cholangiogram period surgical team surgeon doctor p nandakumar period assistant doctor o blake period anesthesiologist doctor lin period anesthesia general endotracheal period

  • appears in this excerpt
  • no mark: from a part of the recording not shown here

What comes back · operative note

Preoperative diagnosis

Symptomatic cholelithiasis. (appears in this excerpt)

Postoperative diagnosis

Symptomatic cholelithiasis. (appears in this excerpt)

Procedure performed

Laparoscopic cholecystectomy with intraoperative cholangiogram. (appears in this excerpt)

Surgical team

Surgeon: Dr. P. Nandakumar. Assistant: Dr. O. Blake. Anesthesiologist: Dr. Lin. (appears in this excerpt)

Anesthesia

General endotracheal. (appears in this excerpt)

Findings

Distended gallbladder with a thickened wall and multiple stones. No evidence of common bile duct dilation. The liver appeared normal.

Description of the technique

The patient was placed supine and prepped and draped in the usual sterile fashion. A 12 mm umbilical port was placed by open technique and pneumoperitoneum established to 15 mmHg. Three additional 5 mm ports were placed under direct vision.

The gallbladder was retracted cephalad and the triangle of Calot dissected. The cystic duct and cystic artery were identified and the critical view of safety obtained. A cholangiogram through the cystic duct showed no filling defects. The cystic duct and artery were each clipped twice proximally and once distally and divided.

The gallbladder was dissected from the liver bed with electrocautery and removed in a retrieval bag through the umbilical port. Hemostasis was verified. The umbilical fascia was closed with 0 Vicryl and the skin with 4-0 Monocryl.

Specimens

Gallbladder to pathology.

Estimated blood loss and transfusions

20 mL. No transfusion.

Complications and incidents

None.

Counts

Correct times two.

Intraoperative studies

Cholangiogram: normal.

Immediate postoperative condition and plan

Extubated in the operating room, hemodynamically stable, to recovery.

Clear liquids tonight, advance as tolerated.

Oxycodone 5 mg every 6 hours as needed.

Discharge tomorrow if tolerating diet; follow-up in 2 weeks.

Implants and devices · Drains and fluids · Prognosis — also part of an operative note; nothing in this example's recording calls for it, so it is left out.

Illustrative example

End of the illustrative example. Neither the excerpt nor the document was produced by Verbato.

What it looks like

Verbato's project screen: the operative note, in its sections, with the transcript folded beside it and a box to ask for a change.
  1. The transcript, folded beside the document: one press opens it, line by line with times.
  2. The document, in its sections.
  3. A change, asked for in your own words.

Verbato's app. The content was written to show it.

A blank operative note to copy

Preoperative diagnosis

The diagnosis the operation was undertaken for.

Postoperative diagnosis

The diagnosis after the operation, which may be the same.

Procedure planned

The operation planned, when it differs from the one performed.

Procedure performed

Each operation performed, one per line, with its laterality and approach.

Surgical team

The surgeon, assistants, anesthesiologist, scrub and circulating staff, one role per line.

Anesthesia

The type of anesthesia.

Indication

The clinical reason for the operation.

Findings

What was found during the operation, in prose, with measurements and units.

Description of the technique

The operation step by step, with sutures, sizes and devices.

Specimens

Each specimen removed and where it was sent.

Estimated blood loss and transfusions

The blood lost, and any product transfused and its quantity.

Complications and incidents

Any complication or incident, or a statement that there was none.

Implants and devices

Each implant with its type, manufacturer, model, size and lot or serial number.

Counts

The sponge, needle and instrument counts.

Intraoperative studies

Any frozen section, imaging or cholangiography, and its result.

Drains and fluids

Drains, tubes and catheters placed; fluids and urine output.

Immediate postoperative condition and plan

The patient's condition and destination at the end, then the immediate plan.

Prognosis

The surgeon's prognosis.

How your operative note is written

  • A section you did not dictate is left out, never filled with a normal finding.

  • Laterality and measurements are written as you dictated them, with their units.

  • Sutures, counts and implant identifiers are written as you said them.

  • The word-for-word transcript sits beside the note, so you check before you sign.

Your format, not ours

The sections of your operative note and the way it is written are yours to change. To fix a document, say what is wrong in your own words.

  1. 1You correct it

    “Call the ‘Procedure performed’ section ‘Operation performed’.”

    That operative note changes. Nothing else does.

  2. 2You say it again

    Make the same correction on a later operative note and Verbato asks: “You've changed this before. Always?”

  3. 3You decide

    Answer “Always” and it is kept as a rule, applied from your next operative note on. Answer “Just this once” and nothing is kept. Documents already written stay as they are, and nothing becomes a rule unless you confirm it.

  4. 4Your rules

    I call the “Procedure performed” section “Operation performed”.Undo

    Every rule you have kept is listed, and you can undo any of them. An undone rule stops applying from your next operative note.

How it works

Upload a file, paste a link, record in your browser, or send a voice note by Telegram or email. Verbato makes a word-for-word transcript, which you can edit and which stays beside the document. Your operative note is written from it, in minutes.

Recording limits

A recording made in your browser can run up to 30 min on every plan; a longer session goes in as a file you upload. A free account takes recordings of up to 40 min each; for longer ones, see pricing.

Your recording

Deleted after 7 days by default, together with its transcript and documents. You can keep a project longer, up to your plan's limit. Deleting a recording leaves a receipt you can download. Nothing you record is used to train or improve AI models. Recording patients or clients? Read what Verbato does with sensitive recordings.

Questions about the operative note

Is an operative note the same as an operative report or an op note?
Yes: the three names are used for the same document, the operating surgeon's account of the operation. Some hospitals also ask for a brief op note right after surgery, a short subset of the same headings, before the full report.
Can I dictate the sections in a different order?
Yes. Say a section's name and carry on: what follows goes into that section, whatever order you dictate in, and a heading the note does not have goes into the closest section. Within a section, your steps keep the order you gave them.
What if I correct myself in the middle of a step?
When you dictate to Verbato, say “scratch that” or “correction” and carry on. The note takes the corrected wording and leaves out the slip. The transcript still shows everything you said.
What happens when a device or a suture is misheard?
Speech recognition can mishear a term. Where the context makes it clear, the note writes the standard name of the device, suture or instrument; otherwise it writes what was heard rather than guess, and an unclear fragment never becomes a step or a finding. Read the note against your dictation before you sign it.
Is the operative note only for general surgery?
No: it is not tied to one specialty or procedure. Orthopedic, gynecologic or urologic, the sections are the same, and each holds only what you dictated for that operation.
How do I get the note into the hospital's record?
Copy the operative note, or export it as a Word document, a PDF or plain text, and paste it where you sign. Verbato has no built-in connection to your hospital's record system.

The guide

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