Standardizing operative notes: The future of surgical documentation at UC Davis Health

Every surgical procedure tells a patient story. That story is captured in the operative note, one of the most important clinical documents in the medical record. 

At UC Davis Health, a major initiative is underway to modernize and standardize operative note documentation across all surgical specialties, ensuring that these critical records are accurate, consistent, and capable of supporting the future of patient care.

The Operative Note Standardization Project is a collaboration between surgical leaders, clinicians, informatics teams, coding and documentation experts, and operational partners. 

The goal is to create a standardized operative note framework that captures the information clinicians need while reducing unnecessary complexity and variation throughout the health system. 

Over time, healthcare organizations often accumulate thousands of note templates, many of which are highly customized, duplicative, or outdated. While created with good intentions, excessive variation can make documentation more difficult to maintain, increase the risk of incomplete documentation, and create challenges when regulatory requirements change. 

Framework to reduce complexity
A standardized approach allows the institution to focus on a single, high-quality documentation framework while still preserving specialty-specific needs through structured customization.

The benefits extend far beyond the documentation process itself. Consistent operative notes help ensure that critical details are captured accurately the first time, reducing the need for follow-up documentation requests and physician queries. 

Improved documentation supports appropriate coding and work RVU attribution, strengthens compliance efforts, enhances quality reporting, and contributes to more accurate measurement of patient acuity and outcomes. 

As healthcare becomes increasingly data-driven, high-quality structured documentation is also essential for analytics, quality improvement, and emerging technologies. For example, standardized documentation creates a stronger foundation for reporting, benchmarking, clinical decision support, and future AI-enabled solutions.

And those outcomes will help UC Davis Health leverage technology more effectively while maintaining a focus on patient-centered care.

Partnership, collaborations
The initiative is being implemented through close partnership with clinical departments and faculty leaders. Early pilot specialties are refining the templates and workflows, ensuring that the final solution reflects the realities of surgical practice while advancing institutional goals.

This collaborative approach allows UC Davis Health to balance standardization with physician input, creating a solution that is both practical and sustainable.

Joseph Galante, Chief Medical Officer - Hospital Clinical Care Services, said, "Standardizing operative notes is an important step in modernizing documentation across UC Davis Health. By adopting a single framework with specialty-specific customization, we can improve documentation integrity, reduce variation, support accurate work RVU capture, strengthen compliance, and provide the high-quality structured data needed to support quality reporting and AI-enabled technologies.”

He noted, “Most importantly, it helps ensure the care we provide is consistently and accurately represented for every patient."

Ultimately, the Operative Note Standardization Project is an investment in clinical excellence, operational efficiency, and the long-term sustainability of healthcare delivery. 

By creating a consistent approach, UC Davis Health is strengthening the integrity of the medical record, supporting providers, and laying the foundation for better patient care in the years ahead.