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Surgical Modules - Operations

OpenEyes provides comprehensive surgical workflow management through two primary modules that work in tandem: OphTrOperationbooking for scheduling surgeries and OphTrOperationnote for documenting procedures.

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Overview

The surgical modules handle the complete perioperative workflow:
  1. Decision to Operate: Made during clinical examination
  2. Operation Booking: Scheduling and pre-assessment
  3. Pre-Operative Preparation: Consent, biometry, medications
  4. Surgical Documentation: Intra-operative record
  5. Post-Operative Care: Follow-up and complication tracking
These modules integrate with OphTrConsent, OphInBiometry, OphTrOperationchecklists, and OphCiExamination to provide comprehensive surgical care documentation.

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OphTrOperationbooking - Operation Booking

The operation booking module manages surgical scheduling from initial listing through to admission.

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Core Elements

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Operation Element

Element_OphTrOperationbooking_Operation
Captures the surgical requirements:
  • Procedures: One or more procedures to be performed
  • Eye: Right, left, or bilateral
  • Anaesthetic Type: Local, general, sedation, or LA with sedation
  • Priority: Routine or urgent
  • Consultant: Operating surgeon or supervising consultant
  • Total Duration: Calculated from procedure durations
  • Comments: Special requirements or considerations
Multi-Procedure Support: Patients can be listed for multiple procedures in a single operation:
  • Combined cataract and glaucoma surgery
  • Bilateral simultaneous procedures
  • Staged procedures with planned interval
Procedure Database:
  • OPCS-4 coded procedures
  • Standard durations
  • Subspecialty grouping
  • Default anaesthetic types
  • Equipment requirements

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Schedule Operation Element

Element_OphTrOperationbooking_ScheduleOperation
Manages the actual scheduling:
  • Session Selection: Theatre list and date
  • Scheduled Time: Planned start time
  • Session Comments: Notes for theatre team
  • Booking Status: Scheduled, rescheduled, cancelled
Session Configuration:
  • Theatre location and room
  • Session start and end times
  • Available time slots
  • Surgeon/anaesthetist assignments
  • Session type (routine, emergency, day case)
Capacity Management:
  • Real-time session availability
  • Automatic duration calculations
  • Overrun warnings
  • Session utilization reporting

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Diagnosis Element

Element_OphTrOperationbooking_Diagnosis
Links surgical indication to diagnosis:
  • Principal diagnosis for operation
  • Laterality
  • ICD-10 coding for data reporting

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Pre-Assessment Element

Element_OphTrOperationbooking_PreAssessment
Tracks pre-operative assessment:
  • Assessment date and outcome
  • Fitness for anaesthesia
  • Special requirements identified
  • Risk stratification

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Contact Details Element

Element_OphTrOperationbooking_ContactDetails
Ensures up-to-date patient contact information for admission letters and communication.

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Booking Workflow

1

Create Booking Event

From patient record or worklist, create new operation booking
2

Enter Operation Details

Select procedures, eye, anaesthetic type, consultant, and priority
3

Record Diagnosis

Link to diagnosis justifying surgical intervention
4

Update Contact Details

Verify patient address and phone number
5

Schedule Operation

Select available theatre session and time slot
6

Pre-Assessment

Arrange and record pre-operative assessment
7

Generate Letters

Send admission letter and GP notification

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Booking Status Management

Scheduled

Operation has confirmed date and theatre slot

Rescheduled

Patient or hospital initiated date change with reason documented

Cancelled

Operation cancelled with reason code (patient, medical, capacity)

On Hold

Temporarily suspended pending additional requirements

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Cancellation Reasons

OphTrOperationbooking_Operation_Cancellation_Reason
Standardized cancellation reasons for audit:
  • Patient declined/DNA
  • Medical reasons (unfit, infection, etc.)
  • Hospital capacity issues
  • List overrun
  • Emergency case prioritization
  • Administrative error

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Waiting List Management

The module supports comprehensive waiting list management:
Patient Prioritization:
  • Routine vs urgent classification
  • Waiting time tracking
  • Target breach alerts
  • Escalation protocols
Worklists:
  • Patients awaiting scheduling
  • Patients awaiting pre-assessment
  • Patients awaiting consent
  • Patients awaiting biometry
  • Operations scheduled by date
Reporting:
  • Waiting time statistics
  • Breach reporting
  • Cancellation analysis
  • Utilization metrics

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Letters and Communication

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Admission Letters

Automatically generated letters include:
  • Date and time of admission
  • Pre-operative instructions (fasting, medications)
  • What to bring
  • Contact information
  • Customizable warnings based on rules
OphTrOperationbooking_Admission_Letter_Warning_Rule
Conditional warnings can be added based on:
  • Patient age
  • Procedure type
  • Anaesthetic type
  • Comorbidities
  • Medications

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GP and Patient Letters

Notifications sent to:
  • General Practitioner (surgery scheduled)
  • Patient (admission details)
  • Optometrist (if applicable)
  • Other care providers

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Theatre Whiteboard

OphTrOperationbooking_Whiteboard_ProcAssignment
Digital theatre board for day-of-surgery management:
  • Patient list for current session
  • Procedure details
  • Arrival status
  • Consent status
  • Biometry status
  • Pupil dilation status
  • Current location (ward, anaesthetic room, theatre, recovery)
  • Delays and issues

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Integration Points

Examination

Surgical decision triggers booking creation from management plan

Consent

Links to electronic consent documentation

Biometry

Tracks completion of pre-operative biometry

Operation Note

Booking details auto-populate operation note

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OphTrOperationnote - Operation Note

The operation note module provides comprehensive surgical documentation with procedure-specific templates.

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Core Elements

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Procedure List

Element_OphTrOperationnote_ProcedureList
Properties:
  • eye_id: Which eye operated (right/left/bilateral)
  • procedures[]: Array of performed procedures
  • booking_event_id: Link to original booking
Validation:
  • Eye selection required
  • At least one procedure required
  • Links to operation booking if available

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Site and Theatre

Element_OphTrOperationnote_SiteTheatre
Records:
  • Hospital site
  • Theatre/operating room
  • Date of surgery

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Surgeon

Element_OphTrOperationnote_Surgeon
Surgical team documentation:
  • Primary surgeon
  • Assistant surgeon(s)
  • Supervising consultant (for training cases)
  • Role of each team member

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Anaesthetic

Element_OphTrOperationnote_Anaesthetic
Anaesthetic details:
  • Type: Topical, subtenons, peribulbar, retrobulbar, general
  • Specific agents used
  • Complications
  • Anaesthetist name

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Procedure-Specific Elements

The module includes specialized elements for different surgical procedures: 
Element_OphTrOperationnote_Cataract
Phacoemulsification Details:
  • Incision type, size, and location
  • Phaco technique (divide and conquer, chop, etc.)
  • Difficulty score
  • Capsulorhexis quality
  • IOL type, power, and position
  • Wound closure method
  • Intraoperative complications:
    • Posterior capsule rupture
    • Vitreous loss
    • Zonular dialysis
    • Descemet’s membrane detachment
    • Other complications
Biometry Integration:
Element_OphTrOperationnote_Biometry
Links to pre-operative biometry for IOL selection verification
Element_OphTrOperationnote_Vitrectomy
Vitrectomy Details:
  • Gauge (20G, 23G, 25G, 27G)
  • Sclerotomy sites
  • Lens status (phakic/pseudophakic)
  • Core vitrectomy completed
  • Peripheral vitrectomy
  • PVD induction method
Additional Procedures:Membrane Peel:
Element_OphTrOperationnote_MembranePeel
  • ILM peel
  • ERM peel
  • Staining used (ICG, BBG, Triamcinolone)
Tamponade:
Element_OphTrOperationnote_Tamponade
  • Gas type and concentration (SF6, C2F6, C3F8)
  • Silicone oil (1000cs, 5000cs)
  • Air or BSS
  • Fill percentage
Buckle:
Element_OphTrOperationnote_Buckle
  • Encircling or segmental
  • Buckle type and size
  • Drain performed
  • Retinopexy method
Trabeculectomy:
Element_OphTrOperationnote_Trabeculectomy
  • Conjunctival incision (fornix-based, limbal-based)
  • Scleral flap size and thickness
  • Sclerectomy/trabeculectomy details
  • Peripheral iridectomy
  • Releasable sutures
  • Bleb appearance
  • Post-op IOP
Tube/Shunt Procedures:
Element_OphTrOperationnote_GlaucomaTube
Element_OphTrOperationnote_RevisionAqueousShunt
  • Implant type (Baerveldt, Ahmed, Molteno)
  • Plate size
  • Tube placement (anterior chamber, pars plana)
  • Tube position and length
  • Patch graft material
MIGS Procedures:
Element_OphTrOperationnote_Trabectome
  • Trabectome, iStent, XEN, etc.
  • Angle approach
  • Degree of treatment
  • Hyphema control
Adjunctive MMC:
Element_OphTrOperationnote_Mmc
  • MMC concentration
  • Duration of application
  • Area of application
  • Washout technique
Corneal Cross-Linking:
Element_OphTrOperationnote_CXL
  • Protocol (Dresden, accelerated)
  • Epithelium on/off
  • Riboflavin application
  • UV dosage and duration
  • Intraoperative pachymetry
Element_OphTrOperationnote_GenericProcedure
For procedures without specific templates:
  • Free-text description
  • Laterality
  • Complications
  • Technique details

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Supporting Elements

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Post-Operative Drugs

Element_OphTrOperationnote_PostOpDrugs
Medications given at end of surgery or prescribed post-operatively:
  • Subconjunctival injections (antibiotic, steroid)
  • Intracameral antibiotics
  • Topical drops to commence
  • Systemic medications
Integrates with OphDrPrescription for post-op medication orders.

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Comments

Element_OphTrOperationnote_Comments
Free-text notes for:
  • Additional operative details
  • Unusual findings
  • Intraoperative decisions
  • Post-operative instructions
  • Follow-up recommendations

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VTE Assessment

Element_OphTrOperationnote_VteAssessment
Venous thromboembolism risk assessment for general anaesthetic cases.

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Surgical Documentation Workflow

1

Pre-Population

If linked to booking, procedure details auto-populate
2

Confirm Procedures

Verify and adjust procedures actually performed
3

Record Details

Complete procedure-specific elements with surgical findings and techniques
4

Document Complications

Record any intraoperative complications with severity and management
5

Post-Op Medications

Specify post-operative drug regimen
6

Sign Off

Surgeon signs and finalizes operation note

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Complication Documentation

Detailed complication recording with:
  • Type: Categorized by complication
  • Severity: Minor, moderate, major, sight-threatening
  • Management: How complication was handled
  • Outcome: Resolution status
Complication data feeds into surgical audit and quality improvement programs.

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Supporting Modules

Electronic consent documentation:
  • Procedure-specific consent templates
  • Risks, benefits, and alternatives
  • Complications and their probabilities
  • Patient information leaflets
  • Electronic signature capture
  • Capacity assessment

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OphTrOperationchecklists - WHO Checklists

Digital WHO surgical safety checklist:
  • Sign In: Before anaesthesia
  • Time Out: Before skin incision
  • Sign Out: Before patient leaves theatre
Tracks:
  • Patient identity confirmation
  • Site and laterality verification
  • Consent confirmation
  • Equipment checks
  • Team briefing
  • Specimen handling
  • Instrument/swab counts

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Surgical Audit & Reporting

Case Volume

Track surgical activity by procedure, surgeon, and time period

Complications

Analyze complication rates and trends

Outcomes

Monitor surgical outcomes and visual results

Waiting Times

Report on time from listing to surgery

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National Audit Integration

Data can be extracted for:
  • National Ophthalmology Database (NOD)
  • Royal College audits
  • Local clinical governance
  • Research databases

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Best Practices

Timely Documentation

Complete operation note immediately after surgery while details are fresh

Accurate Complications

Document all complications honestly for learning and quality improvement

Link to Booking

Always link operation note to original booking for complete audit trail

Verify Details

Confirm patient, eye, and procedure match WHO checklist and consent

Post-Op Instructions

Clearly document post-operative care plan and follow-up arrangements

Teaching Cases

Properly document supervision level for training cases

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Troubleshooting

Possible Causes:
  • No theatre sessions configured for selected date range
  • Selected procedure duration exceeds available session time
  • Theatre not available for selected subspecialty
  • User lacks permission to schedule for selected surgeon
Solutions:
  • Contact theatre coordinator to add sessions
  • Split procedures across multiple sessions
  • Verify theatre configuration
  • Check user permissions
Check:
  • Operation note is correctly linked to booking event
  • Booking has scheduled procedures recorded
  • No data migration issues
  • Create new operation note from booking event directly

Biometry

Pre-operative measurements for cataract surgery

Examination

Post-operative examination findings

User Guide

Step-by-step surgical workflows

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