Documentation/Surgery / OR
Module guide · Clinical
Surgery / OR
One surgical case's entire life: scheduled, confirmed, worked through the WHO Surgical Safety Checklist, tracked minute-by-minute in the OR, counted, closed, sent to PACU, and rolled up into quality statistics.
What this module is for
Every screen is reachable by the whole surgical team, there's no separate surgeon-only or nurse-only view, the module relies on workflow gating (what button appears when) rather than role gating.
Who uses it
Surgeons, anesthesiologists, CRNAs, scrub and circulating nurses, OR schedulers, and quality/compliance staff all work from the same case record, each contributing the tabs relevant to their role.
Where to find it
Open Surgery / OR from the sidebar. Seven screens: a dashboard, Cases, a Live OR Board, OR Schedule (block management), Quality & Statistics, and Import/Export.
- 1
Schedule
A case is booked with a patient, surgeon, procedure, CPT/ICD-10 codes, and a time slot.
- 2
Work the case
Status moves forward step by step, confirmed, arrived, prepped, incision, closing, complete, PACU, discharged, while the team, anesthesia, checklists, counts, implants, specimens, and medications are all charted.
- 3
Sign the report
The operative report is drafted then finalized and locked; clinical notes are signed individually.
- 4
Roll up quality
Every case feeds the Live OR Board, room utilization on the schedule, and NSQIP/TJC/SCIP quality statistics.
A few terms you'll see throughout
Dashboard
Live stat tiles, active emergency cases, and today's schedule, the day's situational overview.
Stat tiles
| Field | What it means |
|---|---|
| In Progress | Cases currently underway. |
| Emergency | Active cases flagged emergency. |
| Today's Cases | Total scheduled today. |
| Awaiting Start | Scheduled or Confirmed, not yet arrived. |
An "Active Emergency Cases" panel (red-bordered) appears whenever any exist; clicking a case, or a row in Today's Schedule, opens it directly. Five nav cards jump into the other module screens.
Scheduling a case
Search, filter, and page through every case; “Schedule Surgery” books a new one.
"Schedule Surgery" form
| Field | What it means |
|---|---|
| Patient, Primary Surgeon* | |
| Anesthesiologist | Optional. |
| Primary CPT Code, Pre-Op ICD-10, Procedure Name, Pre-Op Diagnosis* | Billing/coding fields required at scheduling time. |
| Scheduled Start, Duration (min)* | Duration must be at least 15 minutes. |
| Priority* | Elective, Urgent, Semi-Emergent, Emergent, or Immediate. Defaults Elective. |
| Laterality, Approach, Anesthesia Type, ASA Score | Approach: Open, Laparoscopic, Robotic, Endoscopic, Thoracoscopic, Arthroscopic, Percutaneous, Transcatheter, Stereotactic, Microsurgical, Hybrid, or Natural Orifice. |
| Department, Room | Room list filters to the selected department. |
| Emergency case | Checkbox. |
| Special Instructions |
Filters above the table: free-text search, patient, status, and priority. Export CSV downloads the currently filtered list.
Case lifecycle
Opening a case shows ten tabs: Overview, Team, Anesthesia, Checklists, Count, Implants, Specimens, Medications, Notes & Report, History. The Overview tab drives the status forward one step at a time.
Scheduled → Confirmed — booked, then confirmed
Patient Arrived → Prep Complete — in the building, prepped
In Progress → Closing — incision through closure
Completed → In PACU → PACU Discharged — surgery done through recovery
Cancelled / Postponed / Converted — reason-gated exits or a mid-case approach change
Each forward step is a single button, "Confirm Case," "Mark Patient Arrived," "Mark Prep Complete," "Start Surgery (Incision)," "Begin Closing," "Complete Surgery," "Transfer to PACU," "Discharge from PACU" (with an optional PACU discharge score). Cancel Case and Postpone are available almost any time before completion and each require a typed reason; Cancel is irreversible. Mark Converted (e.g. lap → open), available while In Progress, also requires a typed reason but doesn't block the case from continuing to Closing/Completed.
A "Chart Intraop Data" panel records OR In/Induction/Time-Out/Incision/Closure/OR Out times, EBL, crystalloid/colloid, urine output, blood product units, wound classification, and post-op diagnosis. Outcome flags, unplanned return to OR, surgical site infection, conversion, and antibiotic-given-after-60-minutes (a SCIP measure), surface as badges once set.
Team & anesthesia
Team tab
Add Member picks a staff member and a role (Attending Surgeon, Resident/Fellow Surgeon, PA/RN First Assist, Anesthesiologist, CRNA, Scrub Tech/Nurse, Circulating Nurse, Perfusionist, and more), with a "Primary for this role" flag. Scrub Out records a timestamp; removing a member asks for confirmation first.
Anesthesia tab
Records type, ASA score, airway device, induction/maintenance agents and dose, and flags: NPO Verified, Extubated in OR, MH Event (malignant hyperthermia), and Awareness Confirmed (intraoperative awareness), both are treated as serious safety events and badged red. A separate Vitals log tracks HR, BP, MAP, SpO2, EtCO2, respiratory rate, and temperature over time.
Checklists & counts
The WHO Surgical Safety Checklist and the AORN sponge/sharps/instrument count, the module's two hard safety gates.
Checklists
Five phases can be initialized: Pre-Op, Sign In, Time Out, Sign Out, Post-Op. Each item can be marked Pending, Completed, Not Applicable, Deferred, or Failed; items marked with an asterisk are critical. Once a checklist's overall status is Completed, it locks, no further edits.
Surgical counts
Counts are recorded at three phases, Initial, Closing, Final, for sponges, sharps, and instruments, each with a circulating nurse and scrub nurse/tech ID. A mismatch is flagged DISCREPANCY.
A count discrepancy is a retained-item safety event
Implants, specimens & medications
Three more tabs on the case record
| Field | What it means |
|---|---|
| Implants | Device name and category (Joint Prosthesis, Spinal Implant, Cardiac Device, Vascular Graft, Neurostimulator, Hernia Mesh, and more) are required; manufacturer, catalog/lot number, site, and a scanned UDI are optional. "Recall Check" verifies against recall data. |
| Specimens | Label (A, B, C…) and description are required; laterality, tissue site, Fresh Frozen and Frozen Section Requested flags, and notes are optional. A final pathology diagnosis appears once resulted. |
| Medications | Drug name, dose amount and unit are required; route (PO, IV, IM, SQ, and more), indication, and a "controlled substance" flag are optional, flagged CS with its DEA schedule when checked. |
Notes & operative report
Where the case gets written up and signed off, plus a full audit History tab.
The Operative Report is drafted in a free-text box, saved as a draft, then Finalize & Sign locks it, the editor disappears and it can no longer be changed from this screen. Clinical Notes (Operative, Pre-Op, Post-Op, Anesthesia, Nursing, Consent, Intraop, PACU, or Addendum) are added freely but each can be individually signed, once signed, a note has no unsign option. History is a read-only audit trail of every recorded action and field change, with who performed it and when.
Live OR board
A real-time, auto-refreshing board (every 30 seconds) of every active room, for at-a-glance situational awareness.
How it's organized
Active Emergency Cases get their own pulsing-red panel above the general Active Cases grid, both sorted by room number. Clicking any card opens that case.
What each card shows
Room number, procedure, patient, surgeon, scheduled time, and priority/status badges. A pulsing "Live" indicator confirms auto-refresh is running.
OR schedule (room blocks)
A per-day view of each room's block allocation, booked slots, and utilization, used to set up or adjust a room's block.
New / Update Block form (upsert: same form creates or edits a room's block for the date)
| Field | What it means |
|---|---|
| Room ID, Schedule Date* | |
| Block Owner, Owner Dept ID, Block Start, Block End | |
| Add-On Slots Available | Defaults 0. |
| Room Status | Open, Closed, Blocked, or Hold. Defaults Open. |
| Notes |
Each room card shows a Utilization %, Scheduled/Actual minutes, and Turnover minutes, plus a "First Case On Time" badge, a core perioperative efficiency metric. Booked slots with a linked case are clickable through to case detail.
Quality & statistics
A date-range quality dashboard blending NSQIP, TJC, and SCIP measures with OR efficiency and volume trends.
Stat tiles
| Field | What it means |
|---|---|
| Total / Elective / Emergency / Cancelled / Postponed Cases | |
| OR Utilization, Avg Turnover, 1st Case On-Time | |
| Avg Cut-to-Close, Avg Total OR Time, Avg Anesthesia Time | |
| SSI Rate, Unplanned Return to OR, Conversion Rate, Antibiotic ≤60min (SCIP-INF-1) | Flagged red when nonzero. |
| Avg ASA Score, Awareness Events, Malignant Hyperthermia, Avg Blood Loss, Transfusion Rate |
Retained foreign objects are called out explicitly
Below the tiles: a monthly case-volume trend chart, and breakdowns by status, department, surgical approach, anesthesia type, wound classification, top CPT codes, and complications by category. Import/Export (a separate screen) offers CSV bulk import with a default dry-run validation mode, CSV/JSON/FHIR export, and a dedicated ACS NSQIP 30-day-outcomes CSV export.
Good practices
Chart the Time-Out
Resolve count discrepancies before closing
Cancel, Postpone, and Finalize & Sign are all one-way