How to Write a Veterinary Surgery Report
The surgery report is one of the most important documents you’ll write — and often one of the most rushed, squeezed in between the recovery kennel and the next case. A complete, well-structured report protects the patient, your team, and you. Here’s what belongs in it, and how to stop writing them from scratch after every procedure.
What a complete surgery report covers
A good surgical record walks through the procedure in four clear phases:
Pre-operative. The patient’s signalment, the presenting problem and diagnosis, relevant history and bloodwork, the planned procedure, and the pre-anesthetic assessment (including ASA status). This establishes why you operated and that the patient was fit for it.
Anesthesia. Premedication, induction and maintenance agents with doses, the airway and monitoring used, fluid therapy, and any intra-operative events or interventions. Anesthetic records are frequently scrutinized, so precision matters.
Surgical. The approach, the technique step by step, what you found (normal and abnormal), suture materials and patterns, any complications, and how they were managed. Specifics here are what make the record defensible and useful to whoever reads it next.
Recovery and post-op. How the patient recovered, analgesia provided, and the post-operative plan — medications, activity restriction, wound care, and the recheck interval. This flows directly into the owner’s discharge instructions.
A short template
Pre-op: [signalment, diagnosis, planned procedure, ASA status, relevant history/bloodwork]. Anesthesia: [premed, induction, maintenance, monitoring, fluids, events]. Surgical: [approach, technique, findings, suture materials/patterns, complications + management]. Recovery: [recovery quality, analgesia, post-op plan, aftercare, recheck]. Surgeon: [name]. Date/time: [ ].
Stop writing them from a blank page
Almost everything in a surgery report is something you could describe out loud as you work or immediately after — which makes it a perfect fit for voice. Instead of typing four structured sections from memory once the patient is in recovery, you dictate the procedure and let the structure come for free. That’s the same duplicated documentation problem that eats surgical days.
A veterinary AI scribe closes it. Coggo generates a structured surgery report — pre-op, anesthesia, surgical, and recovery — from your dictation, alongside the SOAP note and a client recap. You describe the case once and review a formatted report instead of building it by hand.
If surgery reports are backing up your surgical days, dictate the next one. Try Coggo free and get the report drafted before the patient’s awake.
This article is general documentation guidance and not a substitute for your clinical judgement or your jurisdiction’s record-keeping requirements.
Frequently asked questions
What should a veterinary surgery report include?
A complete surgery report covers the pre-operative assessment and diagnosis, the anesthetic protocol and monitoring, the surgical procedure with findings and technique, and the recovery and post-op plan including analgesia and aftercare instructions.
Why is a detailed surgical record important?
A thorough surgery report is a medico-legal record, a communication tool for your team and any referral vet, and a reference for follow-up care. It documents what was done, what was found, and what the patient needs next.
How can I write surgery reports faster?
Dictate the procedure as you would describe it and use a veterinary AI scribe to structure it into a formatted surgery report — pre-op, anesthesia, surgical, and recovery — from the same recording, so you review instead of writing from a blank page.