Sign the Peri-Operative Record
Every operation leaves one structured record that travels through three phases: what was assessed and checked before surgery (pre-op), what was actually done during it (intra-op), and how the patient is after it (post-op). The whole surgical team contributes, and when the operative note is complete the surgeon signs it — which locks it permanently as the legal account of the operation. This page walks the team through filling each phase and signing off.
Who / when: the surgeon, the anaesthetist and the scrub nurse, working a case from the moment the patient is prepared through to recovery. The surgeon is the one who signs the locked operative note. We’ll follow Mr. Adeyemi, the surgeon, with his team for Mrs. Eze’s hernia repair.
The words you’ll need:
- Peri-operative record — the single structured record covering the whole operation, organised into Pre-op, Intra-op and Post-op phases.
- eSign PIN — a 6-digit code each clinical staff member has. Typing it is a legal signature: it confirms you authorised this record. It is a separate re-authentication step from your login password.
- Surgeon (or any team member) — open the case from Theatre → Live Board or Theatre → Theatre List to reach its peri-operative record.
- Anaesthetist / surgeon / scrub nurse — work the “Pre-op” phase tab. Complete the pre-operative assessment, the safety checklist and the anaesthetic plan, then press “Save phase”. Saving keeps your work without locking anything — you can come back and add more.
- Surgeon / scrub nurse — during the operation, open the “Intra-op” phase tab. Record the operative findings, the procedure performed, the anaesthesia given and the swab and instrument counts, then press “Save phase”.
- Surgeon / scrub nurse — after the operation, open the “Post-op” phase tab. Record the patient’s recovery status, post-operative instructions and the planned disposition (where the patient goes next — ward, High Dependency Unit (HDU) or ICU), then press “Save phase”.
- Surgeon — when the operative note is complete and correct, press “Sign record”, enter your 6-digit eSign PIN, and confirm. The record now shows “Signed & locked”.
What happens next
Section titled “What happens next”The operative note is now signed, locked and audited — a permanent, tamper-evident account of the operation. The post-op disposition you recorded feeds straight into the next step: the surgeon sends Mrs. Eze to a ward, HDU or ICU through the shared admission. Any implants and consumables used during the case should also be logged against the case so stock is drawn down.