> ## Documentation Index > Fetch the complete documentation index at: https://mintlify.com/appertafoundation/openeyes/llms.txt > Use this file to discover all available pages before exploring further. # Surgical Modules > Operation booking and surgical documentation in OpenEyes # 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. ## 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. ## OphTrOperationbooking - Operation Booking The operation booking module manages surgical scheduling from initial listing through to admission. ### Core Elements #### Operation Element ```php theme={null} 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 #### Schedule Operation Element ```php theme={null} 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 #### Diagnosis Element ```php theme={null} Element_OphTrOperationbooking_Diagnosis ``` Links surgical indication to diagnosis: * Principal diagnosis for operation * Laterality * ICD-10 coding for data reporting #### Pre-Assessment Element ```php theme={null} Element_OphTrOperationbooking_PreAssessment ``` Tracks pre-operative assessment: * Assessment date and outcome * Fitness for anaesthesia * Special requirements identified * Risk stratification #### Contact Details Element ```php theme={null} Element_OphTrOperationbooking_ContactDetails ``` Ensures up-to-date patient contact information for admission letters and communication. ### Booking Workflow From patient record or worklist, create new operation booking Select procedures, eye, anaesthetic type, consultant, and priority Link to diagnosis justifying surgical intervention Verify patient address and phone number Select available theatre session and time slot Arrange and record pre-operative assessment Send admission letter and GP notification ### Booking Status Management Operation has confirmed date and theatre slot Patient or hospital initiated date change with reason documented Operation cancelled with reason code (patient, medical, capacity) Temporarily suspended pending additional requirements #### Cancellation Reasons ```php theme={null} 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 ### 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 ### Letters and Communication #### 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 ```php theme={null} OphTrOperationbooking_Admission_Letter_Warning_Rule ``` Conditional warnings can be added based on: * Patient age * Procedure type * Anaesthetic type * Comorbidities * Medications #### GP and Patient Letters Notifications sent to: * General Practitioner (surgery scheduled) * Patient (admission details) * Optometrist (if applicable) * Other care providers ### Theatre Whiteboard ```php theme={null} 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 ### Integration Points Surgical decision triggers booking creation from management plan Links to electronic consent documentation Tracks completion of pre-operative biometry Booking details auto-populate operation note ## OphTrOperationnote - Operation Note The operation note module provides comprehensive surgical documentation with procedure-specific templates. ### Core Elements #### Procedure List ```php theme={null} 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 #### Site and Theatre ```php theme={null} Element_OphTrOperationnote_SiteTheatre ``` Records: * Hospital site * Theatre/operating room * Date of surgery #### Surgeon ```php theme={null} Element_OphTrOperationnote_Surgeon ``` Surgical team documentation: * Primary surgeon * Assistant surgeon(s) * Supervising consultant (for training cases) * Role of each team member #### Anaesthetic ```php theme={null} Element_OphTrOperationnote_Anaesthetic ``` Anaesthetic details: * Type: Topical, subtenons, peribulbar, retrobulbar, general * Specific agents used * Complications * Anaesthetist name ### Procedure-Specific Elements The module includes specialized elements for different surgical procedures: ```php theme={null} 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:** ```php theme={null} Element_OphTrOperationnote_Biometry ``` Links to pre-operative biometry for IOL selection verification ```php theme={null} 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:** ```php theme={null} Element_OphTrOperationnote_MembranePeel ``` * ILM peel * ERM peel * Staining used (ICG, BBG, Triamcinolone) **Tamponade:** ```php theme={null} Element_OphTrOperationnote_Tamponade ``` * Gas type and concentration (SF6, C2F6, C3F8) * Silicone oil (1000cs, 5000cs) * Air or BSS * Fill percentage **Buckle:** ```php theme={null} Element_OphTrOperationnote_Buckle ``` * Encircling or segmental * Buckle type and size * Drain performed * Retinopexy method **Trabeculectomy:** ```php theme={null} 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:** ```php theme={null} 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:** ```php theme={null} Element_OphTrOperationnote_Trabectome ``` * Trabectome, iStent, XEN, etc. * Angle approach * Degree of treatment * Hyphema control **Adjunctive MMC:** ```php theme={null} Element_OphTrOperationnote_Mmc ``` * MMC concentration * Duration of application * Area of application * Washout technique **Corneal Cross-Linking:** ```php theme={null} Element_OphTrOperationnote_CXL ``` * Protocol (Dresden, accelerated) * Epithelium on/off * Riboflavin application * UV dosage and duration * Intraoperative pachymetry ```php theme={null} Element_OphTrOperationnote_GenericProcedure ``` For procedures without specific templates: * Free-text description * Laterality * Complications * Technique details ### Supporting Elements #### Post-Operative Drugs ```php theme={null} 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. #### Comments ```php theme={null} Element_OphTrOperationnote_Comments ``` Free-text notes for: * Additional operative details * Unusual findings * Intraoperative decisions * Post-operative instructions * Follow-up recommendations #### VTE Assessment ```php theme={null} Element_OphTrOperationnote_VteAssessment ``` Venous thromboembolism risk assessment for general anaesthetic cases. ### Surgical Documentation Workflow If linked to booking, procedure details auto-populate Verify and adjust procedures actually performed Complete procedure-specific elements with surgical findings and techniques Record any intraoperative complications with severity and management Specify post-operative drug regimen Surgeon signs and finalizes operation note ### 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. ## Supporting Modules ### OphTrConsent - Consent Forms Electronic consent documentation: * Procedure-specific consent templates * Risks, benefits, and alternatives * Complications and their probabilities * Patient information leaflets * Electronic signature capture * Capacity assessment ### 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 ## Surgical Audit & Reporting Track surgical activity by procedure, surgeon, and time period Analyze complication rates and trends Monitor surgical outcomes and visual results Report on time from listing to surgery ### National Audit Integration Data can be extracted for: * National Ophthalmology Database (NOD) * Royal College audits * Local clinical governance * Research databases ## Best Practices Complete operation note immediately after surgery while details are fresh Document all complications honestly for learning and quality improvement Always link operation note to original booking for complete audit trail Confirm patient, eye, and procedure match WHO checklist and consent Clearly document post-operative care plan and follow-up arrangements Properly document supervision level for training cases ## 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 ## Related Documentation Pre-operative measurements for cataract surgery Post-operative examination findings Step-by-step surgical workflows