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Theatre Clinical Details
The Clinical Details page allows theatre staff and doctors to record operative notes, surgery timing (start and end times), and the composition of the surgical team for each procedure. This information supports clinical documentation requirements and is available for review in the patient's records.
- Immediately after or during a surgical procedure to document operative findings
- To record the surgical team (surgeon, assistants, anaesthetist) for a procedure
- To update surgery start and end times for OT utilisation tracking
- Whenever operative notes need to be captured against a surgery
TheatreAddSurgery
From the Surgery Workbench:
- Open the Surgery Workbench for the patient (see Surgery Workbench)
- Click Clinical Details button
From the Theatre menu:
- Click Theatre → Add Surgeries
- Select the patient and surgery
- Click Clinical Details
The Clinical Details page has two main sections:
| Field | Description |
|---|---|
| Surgery Name | Display only — shows the procedure name (cannot be changed here) |
| Start Time | Date and time the surgery began — click the calendar icon to set |
| End Time | Date and time the surgery concluded — click the calendar icon to set |
| Operative Notes | Free-text field for documenting findings, technique, and intraoperative events |
This section records all staff involved in the surgery, each with a specific role.
- Set the Start Time using the calendar/time picker
- Set the End Time using the calendar/time picker
- Enter the Operative Notes in the text area — document findings, technique, complications, and any relevant clinical information
- Click Save Details (green button)
- A success message confirms the details have been saved
- In the right panel, select the staff member's Role from the dropdown:
| Role | Used For |
|---|---|
| Performed By | Primary surgeon / operator |
| Assisted By | Assistant surgeon(s) |
| Anaesthesia By | Anaesthetist |
- Select the Speciality from the autocomplete — this filters the doctor list
- Select the Doctor / Staff name from the autocomplete (filtered by the selected speciality)
- Optionally enter a Note about this team member's involvement
- Click Add to Team
- The staff member appears in the surgical team table below
Repeat for each team member. Multiple assistants and a single anaesthetist can be added.
The team table shows all staff added to this surgery:
| Column | Description |
|---|---|
| Role | The clinical role (Performed By, Assisted By, Anaesthesia By) |
| Name | Doctor / staff name |
| Notes | Optional note |
| Added By | The system user who recorded this entry |
| Remove | Button to remove this team member (available while admission is not finalised) |
To remove a team member, click the Remove button next to their entry and confirm.
- "Details Saved Successfully" — Surgery timing and operative notes have been saved
- "Please select a staff member" — A doctor must be selected from the autocomplete before clicking Add to Team
- "Please select a role" — A role must be chosen before adding a team member
- "Admission has been finalised" — No changes can be made once the patient's bill is closed
- Record the surgical team immediately after the procedure while the information is readily available
- Use the Notes field for team members to capture any specific contribution (e.g., "First assistant for closure")
- Operative notes should be detailed enough to meet clinical documentation standards — include findings, technique, any complications or unexpected events
- Start and end times are important for OT utilisation reports — always record them accurately
Note: The surgical team recorded here is for clinical documentation purposes. To add professional fee charges for surgeons and anaesthetists, use the Managing Professional Fees screen — these are billed separately.
- Surgery Workbench — Access point for clinical details
- Managing Professional Fees — Billing charges for the surgical team
- Theatre — Adding a Surgery
- Theatre Management Module Overview