Clinical records

Surgery planning and record stages

Planning, team, checklist, surgical stages, and signing.

Platform · Last verified:

A surgery record contains planning and pre/intra/post-operative documentation. Verify patient, procedure, time, team, and consent.

Create the plan

Open Create Surgery from the list. Select patient/type and review scheduling, duration, preparation, and team. Validate defaults against the real procedure. Reopen the result and any Calendar projection to verify time/assignment.

Types and checklist templates have separate management screens. A template change does not automatically rewrite every existing surgery.

Prepare

In Pre-Op, review patient/preparation, required checklist items, and consent. Complete required items before starting. Read reset confirmation before replacing existing checklist progress with a template.

Preparing consent and capturing a signature are distinct. Check the same patient and correct procedure relationship.

Surgery and recovery

Overview, Pre-Op, Intra-Op, Post-Op, and Team contain different records. Advance scheduled, pre-operative, surgical, recovery, and completed stages through permitted actions. Record actual time, observations, and materials.

For materials, verify quantity/unit and inventory source. Editing/deleting usage can affect stock; inspect movements. Cancellation and material correction are distinct.

Complete and sign

Review team, phase content, and documents before completion. Use signing for an eligible completed record. Many edits are unavailable on signed/cancelled records.

On conflict, reload and review newer work. Refreshing does not itself resolve a clinical-condition warning.

Types and checklist management

In Surgery → Types, open creation/permitted editing and review name, category, planning/pricing and offered defaults. In Checklist templates, edit items, order and requiredness. A template preview differs from checking the actual surgery's Pre-Op list. Replacing a template on an existing surgery can reset progress.

Postpone, team and recovery

Use Postpone surgery while scheduled/pre-operative; verify the new clinic date/time and optional reason. It moves the source calendar appointment; do not create another independent event.

In Team, choose roles/staff; record actual timing/findings/material consumption in Intra-Op, and recovery/complications/measurements in Post-Op. Recheck quantity/unit and stock after material edits.

Pending/failed/conflict state may offer Save now. Finish unsaved work before advancing, signing or cancelling. Required-checklist feedback returns to the live Pre-Op item. Text undo shortcuts do not undo lifecycle/sign/cancel actions.

Follow scheduled → pre-operative → surgery → recovery → completed → signed. Signed/cancelled records are read-only. Confirm cancellation reason; do not assume cancellation also completes material/sale/payment corrections.

Anesthesia · Consent · Examination

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