General Surgery Module

February 2026 · 5 min

Overview

The General Surgery module supports surgical case documentation, wound management, and OT (operation theatre) workflow integration. It provides structured operative note templates, surgical safety checklists, wound assessment tools, and post-operative monitoring.

The module includes two sub-pages: Surgical Cases and Wound Management.

Surgical Case Management

The Cases sub-module (General Surgery > Cases) provides:

• Case Registry -- All surgical cases with diagnosis, procedure planned, surgeon, anaesthetist, and scheduled OT date.
• Pre-Operative Assessment -- Structured template covering:
  • Surgical fitness evaluation (ASA grade)
  • Pre-op investigations checklist (CBC, coagulation, blood grouping, chest X-ray, ECG, anaesthesia fitness)
  • Consent documentation (procedure, risks, alternatives explained)
  • Marking of surgical site (WHO surgical safety)
  • Blood/blood products arrangement
  • NPO status confirmation
• Operative Notes -- Structured template with:
  • Procedure name (ICD-10-PCS and CPT coding)
  • Surgeon and assistant names
  • Anaesthesia type and agents used
  • Patient position
  • Incision type and approach
  • Intra-operative findings
  • Procedure performed (step-by-step)
  • Drain placement, suture material, closure technique
  • Specimens sent for histopathology
  • Estimated blood loss
  • Intra-operative complications
  • Post-operative instructions
• WHO Surgical Safety Checklist -- Three-phase verification:
  1. Sign-in (before anaesthesia): Patient identity, procedure, site, consent, allergies
  2. Time-out (before incision): Team introduction, procedure confirmation, anticipated events
  3. Sign-out (before leaving OT): Procedure performed, instrument/sponge count, specimens, post-op plan

Wound Management

The Wounds sub-module (General Surgery > Wounds) includes:

• Wound Assessment -- Standardised documentation:
  • Location (body map with anatomical marking)
  • Dimensions (length, width, depth in cm)
  • Wound type (surgical, traumatic, pressure, diabetic, venous, arterial)
  • Wound bed (granulating, sloughy, necrotic, epithelialising)
  • Exudate type and amount
  • Peri-wound skin condition
  • Wagner classification (for diabetic foot ulcers)
  • Braden Scale (for pressure injury risk assessment)
• Photo Documentation -- Serial wound photographs with ruler/scale for size tracking. Side-by-side comparison of wound progression over time.
• Treatment Plan -- Dressing type, frequency, offloading devices, negative pressure wound therapy (NPWT), debridement scheduling.
• Healing Progress -- Wound area trend chart showing reduction in size over time. Auto-calculated healing rate (% reduction per week).

Post-Operative Monitoring

After surgery, structured monitoring includes:

• Vital signs monitoring with configurable frequency (every 15 min in recovery, hourly on ward)
• Drain output measurement and trend
• Pain assessment (NRS/VAS scale) with analgesia documentation
• Surgical site inspection (SSI surveillance for 30 days)
• DVT prophylaxis compliance tracking
• Early mobilisation checklist
• Diet progression (nil oral to clear fluids to soft diet to regular)
• Suture/staple removal scheduling

All monitoring data feeds into the discharge summary automatically.

Surgical Outcome Tracking

Quality metrics tracked per surgeon and department:

• Surgical site infection (SSI) rate
• Unplanned return to OT within 48 hours
• 30-day readmission rate
• Average length of stay by procedure
• Blood transfusion rate
• Mortality and morbidity reviews
• WHO checklist compliance rate

These metrics are available on the surgical dashboard and in the hospital's quality reports.

Notes

Related topics