Surgery

Last updated: 2026-03-29

Overview

The Surgery module tracks all aspects of a surgical operation. It allows clinical staff to record the main procedure, patient risk factors, the surgical team, anaesthesia details, and safety checklists. To save administrative time, the module can also automatically generate billing charges for the surgery.

When Do I Use This?

  • When scheduling or logging a surgical operation for a patient.
  • When assessing a patient's cardiac risk before an operation.
  • When completing required surgical safety checklists (e.g., WHO Surgical Safety Checklist) in the operating theater.
  • When the anaesthetist needs to record the type of anaesthesia and specific medications administered during the surgery.

How To Use

1. Recording a New Surgery

  1. Go to the Surgery module from the main menu.
  2. Click + New to create a new surgery record.
  3. Select the Patient and the Main Procedure being performed.
  4. Select the Theater (operating room) and the primary Surgeon.
  5. Tick the relevant medical history checkboxes (e.g., Ischemic Heart Disease) under the risk assessment section.
  6. Enter the Time Start and Time End.
  7. Click Save.
Tip: Once you save a new surgery, the system automatically bills the patient for the Main Procedure (if the procedure has a set billing price). You do not need to enter the main surgical charge manually.

2. Managing the Surgical Team

If multiple professionals are involved, you can log the whole team.

  1. Open the surgery record and scroll to the Team section.
  2. Click to add a new team member.
  3. Select the staff Member and their Role (e.g., Scrub Nurse, Perfusionist).
  4. Click Save.

3. Logging Anaesthesia & Medications

  1. Within the surgery record, go to the Anaesthesia section.
  2. Select the Anaesthetist, the Type of anaesthesia, and the Technique used.
  3. Log the anaesthesia start and end times.
  4. To record specific drugs, open the anaesthesia record's Medication sub-section.
  5. Add the Medicament, the Dose Amount, the Unit, and the Time Administered.

4. Completing Safety Checklists

  1. In the surgery record, find the Checklist section.
  2. Add a new checklist item.
  3. Select the specific Check (e.g., "Patient Identity Confirmed").
  4. Select the Timing (e.g., "Sign In / Before Induction").
  5. Select the State (e.g., "Passed").
  6. Note who performed the check in the Checked By field.

Field Descriptions

Main Surgery Fields

Field Name Description
Procedure Main The primary surgical operation being performed.
Condition Main The main disease or diagnosis requiring the surgery.
Theater The specific operating room where the surgery takes place.
RCRI Revised Cardiac Risk Index. A score automatically calculated by the system (0-6) based on the risk checkboxes you tick. It indicates the patient's risk of cardiac complications. This field is read-only.

Preoperative Risk Checkboxes

Ticking these boxes automatically increases the patient's RCRI score:

Field Name Description
High Risk Surgery Tick if the procedure itself is classified as high-risk (e.g., intraperitoneal, intrathoracic, or suprainguinal vascular procedures).
Ischemic Heart Disease History Tick if the patient has a history of ischemic heart disease.
Congestive Heart Failure History Tick if the patient has a history of heart failure.
Cerebrovascular Disease History Tick if the patient has a history of stroke or TIA.
Preoperative Treatment Insulin Tick if the patient requires insulin treatment for diabetes.
Preoperative Creatinine Tick if the patient has elevated preoperative serum creatinine (typically >2.0 mg/dL).

Checklist Fields

Field Name Description
Timing When the check was performed (e.g., Before skin incision, Before patient leaves the room).
State The result of the check (e.g., Confirmed, Not Applicable).
Tip: If additional procedures are performed during the main surgery (e.g., a secondary hernia repair during an appendectomy), you can add them in the Procedure section inside the surgery record to ensure accurate medical history tracking.
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