Hospital surgery and ward software: one operation, from the decision to the discharge note

Hospital surgery and ward software proves itself when someone asks, months later, what was done to a patient, by whom, with which implant, and what they were told at discharge. On paper that answer is split between a consent folder, a theatre checklist, a late operative note and a bedside drug chart. This guide follows one planned operation through surgery and the ward in OPALEVI, then lists questions for any system.

By the OPALEVI teamPublished 18 October 202611 min read

The surgical procedure record of a visit in OPALEVI: an empty indication box, urgency as elective, urgent or emergency, an anaesthesia select, ASA class I to VI, anticoagulants and antiplatelets with None chosen, the date the last dose was stopped, informed consent and the date of consent.

Key takeaways

Keep one record per operation: assessment, consent, the three checklist stages, what was done, the implant's batch and the complication grade.
Link the theatre list, the beds and the record, so a booking made from the visit heads the operative note.
Ward work runs in shifts: nurses need each shift's doses, room by room, recorded as given, refused, held or missed.
Software should keep what the team confirmed, and never tick a checklist item or grade a complication itself.

Why a surgical department outgrows paper and general software

A general clinic program copes with the outpatient side of surgery. An operation is different: a team, a room booked for hours, a night on the ward, medicines by the clock and a paper the patient takes home. Kept on separate sheets, it breaks in familiar ways:

The recall nobody can answer. A batch of mesh is recalled, and the only trace of who received it is stickers in paper charts.
One surgeon, two theatres. Overlapping bookings go unnoticed until the second list is called.
The dose between shifts. Each shift assumed the other had given it.
The discharge letter from memory. Typed after the patient has left, from what the surgeon recalls of the round.

None of this is carelessness: the facts of one operation are split between theatre, ward and office, and good software joins them.

A fair test for any surgical record: could a colleague who was not in theatre reconstruct the operation from it alone?

What a surgical procedure record has to hold

Whatever you use, paper included, an operation's record should answer these questions without a phone call:

The minimum a surgical procedure record should hold
Field	Why it matters
Indication and urgency	Why the operation is done, and how soon.
Anaesthesia and ASA class	The planned anaesthesia and the patient's physical status.
Anticoagulants	Which blood thinners, and the day of the last dose.
Informed consent	How it was given, by whom, and on which day.
Site and side	Marked on a figure, never left to memory.
Safety checklist	What was confirmed at each of its three stages.
What was done	Procedure, findings, duration, blood loss, specimens, drains and closure.
Implant and batch	The LOT number: the only way to find patients after a recall.
Complications and plan	A Clavien–Dindo grade, a sentence on what happened, and the next review.

The checklist follows the three pauses of the WHO Surgical Safety Checklist: sign in, time out, sign out. ASA is the American Society of Anesthesiologists' physical status scale, and Clavien–Dindo the published grading of complications. Applying them is the team's training, not the software's.

The record keeps what people decided

It should never suggest an ASA class, tick a checklist stage or grade a complication. An unanswered question stays visibly empty.

Before theatre: one patient, step by step, in OPALEVI

Here is one planned operation in the Surgery department of OPALEVI for hospitals. Bold words are the labels on screen.

The consultation
A nurse can enter the Vital signs and prepare the visit; the surgeon writes the complaints, examinations and diagnoses. Each section shows who last wrote in it.
The pre-operative assessment
The Surgical procedure record holds the Indication, Urgency and Anaesthesia, then ASA class I to VI, Anticoagulants and antiplatelets (several, or None) and Stopped on (last dose).
Consent
The record states how Informed consent was given and when; the signed form goes under Patient consents, with its exact text and an optional scan, and is never edited.
Mark the site
Under Site marking, the surgeon pins the Operative site on a body figure, with a note on each pin.
Book the theatre
Book theatre, on the visit's Theatre panel, opens the theatre board on this visit, so the booking is linked to it. Clashes are refused: the same theatre, the same surgeon or the same patient at overlapping times.
Admit to a bed
Patient rooms → Admit patient puts the patient in a free bed with the reason Before surgery, and attaches that day's open visit to the stay.

A surgery visit in OPALEVI: buttons for the prescription, referral letter, operative note, instructions and report; a Theatre panel with no booking yet and a Book theatre button; nurse-recorded vital signs. — The theatre booking, the operative note and the patient's instructions all hang from this one visit.

The theatre list

Operating theatres, under Calendar → Operations, gives each theatre a card for the day. A booking goes from Scheduled to In progress with Start, then to Completed with Complete, or ends with Cancel operation; once started, it can no longer be edited. By default doctors and reception book, nurses can read the board, and only an administrator deletes.

The Operating theatres board in OPALEVI: two theatres on one day, each with three bookings showing procedure, hours, patient, surgeon and status, and buttons to start, complete, cancel or edit them. — A card per theatre shows how far each list has got, without a call to theatre.

In theatre and after: the checklist, the maps and the papers

In theatre the same record keeps filling, often by different hands, and Change history keeps each change with its author and a before-and-after comparison.

Surgical safety checklist: Before anaesthesia, Before the incision and Before leaving theatre, each a short list the team ticks itself, from identity and site marking to swab counts and the recovery plan.
Team: surgeon, assistant, anaesthetist and scrub nurse, written as names; colleagues with accounts go under Assisting staff.
Procedure: findings, duration, Blood loss, specimens and where they went, drains and Skin closure.
Operative note details: the diagnoses before and after, and the Description of the procedure in the surgeon's words.
Incision map: one pin per incision or port on the abdominal wall, each with its type and length.
After the procedure: wound, pain from 0 to 10, Complications — Clavien-Dindo, Postoperative plan, Next review, Implant / material and Implant LOT / batch.

The incision map in OPALEVI: a photographed male abdomen seen from the front, its regions outlined in dashed lines, with one numbered pin low on the patient's right. — Each incision is its own pin, so a four-port laparoscopy reads as four lines on the operative note.

What prints

Operative note, headed by the theatre booking, then diagnoses, team, anaesthesia, findings, technique, incisions, operation data and plan. The checklist stays in the record; only a ticked swab count prints.
Instructions after the procedure: instructions by topic, wound care, activity, warning signs, the next review and who to call. It starts empty, because OPALEVI supplies no ready-made advice.
Print prescription, Print referral letter and the visit Report, on the hospital's letterhead.

Plainly: blood loss, duration and the implant batch are typed, and OPALEVI calculates nothing from them; the implant is text, not a link to stock.

On the ward: beds, doses and the discharge note

In a hospital, Patient rooms sits right after the visit list, and on a nurse's phone it is the first tab after Today. Each occupied bed shows its patient, when they came in and why: before or after surgery, observation or an overnight stay. Move to another bed keeps both stays on file, and Discharge frees the bed.

The Patient rooms board in OPALEVI: eight of twelve beds taken across two surgery rooms, a cardiology room and a paediatrics room, each with its patient and reason, the rest marked free. — Who lies in which bed, since when and why, on one board.

The medication round

Doctors order on the patient's Medication tab with New order; orders are never edited, only stopped and replaced. Nurses record each dose in the Medication round as Given, Refused, Held or Missed, adding the time and a witness under Time and witness when needed. Recording a dose does not move stock. The nursing home guide walks through the round shift by shift.

The discharge note

Freeing a bed and writing the discharge note are separate acts. Under Discharge notes, Issue a discharge note, pick a Template and complete its text; a new hospital starts with a General discharge note whose headings run from admission to follow-up. The note stays editable until Finalise locks it. It is not filled from the operation: the clinician writes it.

The rest of the hospital

From Emergency. A patient is sent on with Refer to a department, and Surgery finds the request under Asked of us on Today; the emergency department guide covers that first hour.
Laboratory and imaging. Request Analyses from the surgical visit; the radiology guide covers imaging.
Billing. Invoice this visit bills the services, and with stock on, a service's Materials used leave the shelf when the visit is saved.
Access. Reception books theatres and admits patients but reads no clinical history unless the hospital switches on Reception may see patients' visit history; finance never does.

Questions to ask before choosing hospital surgery and ward software

Test every system's answers with a real operation from last week, not a demonstration.

Choosing surgical and ward software: the questions, and OPALEVI's answers
Ask	A good answer	In OPALEVI
One record for the whole operation?	Assessment, checklist, procedure and plan together.	Yes: the Surgical procedure record.
Checklist kept by stage?	Three stages, nothing pre-ticked.	Yes, ticked by the team.
Theatre clashes refused?	No double-booked theatre, surgeon or patient.	Yes, all three.
Booking tied to the record?	The operative note shows where and when.	Yes, through the visit's Theatre panel.
Beds with reasons?	A ward board showing who, since when and why.	Yes: Patient rooms.
Implant traceable by batch?	Implant and LOT kept with the operation.	Partly: typed per operation, with no stock link and no search by batch.
An anaesthesia chart?	Intraoperative vitals and drugs over time.	No: the type of anaesthesia and the ASA class only.
Discharge note from the record?	Diagnosis, procedure and medicines pulled in.	No: a template the clinician completes, then finalises.
Cost as you grow?	Predictable, whatever the bed count.	Per staff member; beds, theatres and patients are not counted.

For a wider checklist, read how to choose clinic software.

Your first week: from sign-up to the first operation

Registering as a hospital suggests Surgery among the departments and switches on the theatre board and patient rooms; the theatres, rooms and beds are yours to add. First steps on Today covers the rest:

Set up theatres and wards
Add theatres under Manage theatres, then rooms and beds on Patient rooms.
Set the price list
Replace the three sample surgical services through Add your services and prices.
Prepare the papers
Set up the report letterhead, and adapt the discharge template to your surgeons' headings.
Invite the team
Invite your colleagues, each with an account and a role of their own.
Run one real case
Book, admit, tick the checklist, give the round's doses, print the instructions, and book the review with Email the patient a reminder the day before ticked.

Start with one elective list

Run one surgeon's elective list in OPALEVI for a week, paper alongside, and judge it on Friday. The rest of what OPALEVI does is on the features page.

Frequently asked questions

What is hospital surgery and ward software?

Software that keeps each operation in one record, from the pre-operative assessment and safety checklist to complications and the post-operative plan, and links it to the theatre list, the beds, the medication round and the discharge note, so authorised colleagues read the same account.

Does OPALEVI fill in the surgical safety checklist automatically?

No. The theatre team ticks each of the three stages item by item, and an unticked item stays unticked. The operative note prints the swab and instrument count only when someone recorded it as correct. OPALEVI keeps what was confirmed and who wrote it down.

Can reception read the operation notes?

Not by default. Reception books theatres, admits patients to beds and takes payment, but sees no clinical history unless the hospital turns that on in its settings. Finance never reads clinical records, and a department can limit its records to its own staff.

Does it work on a phone or tablet on the ward?

Yes. A computer, tablet or phone with a browser is all OPALEVI needs on the ward; nothing is installed. On small screens a bottom bar replaces the top menu, and in a hospital the patient rooms are the first tab after Today on a nurse's phone.

Can I try OPALEVI before paying?

Yes. Registering as a hospital starts a free trial, no card required. Put a real elective list through it, from booking to discharge note. If it ends without a plan, no charge is made: the account turns read-only and its operations, stays and notes remain.

How is OPALEVI priced for a hospital?

By the number of staff who use it, and the yearly plan costs less per month than paying monthly. Beds, theatres, patients and departments are never counted: a new ward costs nothing, a new nurse adds one seat. Figures and a calculator are on the pricing page.