2, determine the patient's main condition and surgical purpose, describe the patient's symptoms and related examination results.
3. Describe in detail the methods and steps used in the operation, including anesthesia methods, surgical instruments and techniques.
4. Describe the specific operations during the operation, including organ dissection, tissue resection, hemostasis, suture, etc.
5. Record any complications during the operation, such as bleeding, infection or other unexpected situations, and describe the treatment measures taken by the doctor.
6. Describe the results after the operation, including the status of the operation site, hemostasis and possible improvement.
7, the doctor should sign at the end of the record, and indicate the date and time of the record.