MedCore

OT Session Chart

Abdul Karim MRN MRN-OT-2201 58y · Male Central Branch OT · OT-02 · Total Hip Replacement (Right)
Allergies: Penicillin

Surgery SUR-26-0147

In OT
Procedure
Total Hip Replacement (Right)
Surgeon
Dr. Tom Alexander
Anesthetist
Dr. Nusrat Jahan
OT Room
OT-02
Priority
Elective
ASA
ASA II
Scheduled
2026-08-12 09:00

Patient Timeline

Surgery Requested (07:30)
Pre-op Assessment (08:00)
Consent Signed (08:15)
Approved (08:30)
Scheduled (08:45)
Patient Arrived OT (08:50)
Anesthesia Started (09:05)
Surgery Started (09:30)
Surgery Completed
PACU
Ward Transfer

Clinical Information

Diagnosis
Osteoarthritis, Right Hip (Severe)
Procedure Code
PRC-0012
Indication
Progressive joint pain, failed conservative management
Laterality
Right
Site
Right Hip Joint
Expected Duration
2.5 hours
Requested By
Dr. Tom Alexander (Orthopedics)

Approval Chain

StageStatusByDate
Surgeon Review ApprovedDr. Tom Alexander2026-08-11 16:00
Anesthesia Review ApprovedDr. Nusrat Jahan2026-08-11 17:30
Pre-op Clearance ClearedDr. Meera Nair (Medicine)2026-08-12 07:00
OT Approval ApprovedOT Manager2026-08-12 07:15

Clinical Assessment

Comorbidities
Hypertension, Type 2 Diabetes Mellitus
Previous Surgeries
Appendectomy (2010)
Previous Anesthesia History
No complications
Current Medications
Metformin 500mg BD, Amlodipine 5mg OD
Vital Signs
BP 128/82, HR 76, Temp 36.8°C, SpO2 98%
Airway Assessment
Mallampati Class II
ASA Classification
ASA II
Surgical / Anesthesia Risk
Low–Moderate / Low

Investigation Review

InvestigationStatusResult
CBC ResultedHb 13.2 g/dL, WBC 7.1×10⁹/L
Blood Group ResultedO+
Coagulation Profile ResultedNormal (PT/INR/aPTT)
Renal Function ResultedNormal
ECG ResultedNormal sinus rhythm
X-ray Right Hip ResultedSevere degenerative changes
Cardiology Opinion ResultedCleared for surgery

Pre-Op Clearance

SpecialtyStatusDoctorDateRemarks
SurgeonClearedDr. Tom Alexander2026-08-11—
AnesthetistClearedDr. Nusrat Jahan2026-08-11—
MedicineClearedDr. Meera Nair2026-08-12—
CardiologyCleared with ConditionsDr. Rajesh Kumar2026-08-11Continue antihypertensives morning of surgery

Surgical Consent

Consent Type
General Surgical + Anesthesia Consent
Patient / Guardian
Abdul Karim (self)
Witness
Ayesha Siddika, RN
Doctor
Dr. Tom Alexander
Date / Time
2026-08-11 18:00
Version
v2 (v1 superseded — site corrected from Left to Right)

Pre-Op Checklist

Sourced from the configurable checklist master — see Checklist Configuration.

  • Patient identity verified Completed
  • UHID verified Completed
  • Procedure verified Completed
  • Surgical site verified Completed
  • Consent available Completed
  • Allergy checked Completed
  • Blood group confirmed Completed
  • Blood available Completed
  • Required investigations completed Completed
  • Imaging available Completed
  • Anesthesia clearance Completed
  • Antibiotic requirement checked Completed
  • Fasting confirmed Completed
  • Dentures removed Completed
  • Jewelry removed Completed
  • Valuables secured Completed
  • Pre-op medication given Completed
  • Patient prepared Completed
  • Surgical site marked Completed

Surgical Site Verification

Correct Patient
Verified
Correct Procedure
Verified
Correct Site / Laterality
Right — Verified
Site Marking
Completed (Dr. Tom Alexander)

Staff Assignment

RoleNameConflict Check
SurgeonDr. Tom Alexander No Conflict
Assistant SurgeonDr. Wei Zhang No Conflict
AnesthetistDr. Nusrat Jahan No Conflict
Scrub NurseSultana Begum No Conflict
Circulating NurseAyesha Siddika No Conflict
OT TechnicianHabibur Rahman No Conflict
PerfusionistN/ANot Required (non-cardiac case)

Equipment Checklist

  • OT Table Ready
  • Electrocautery Ready
  • C-Arm Ready
  • Suction Ready
  • Orthopedic Power Drill Ready
  • Special Broach Set (Size 6) Unavailable

Instruments

Set
Orthopedic Hip Set #OT2-14
Sterilization Cycle
CSSD-26-0810
Tray
2 of 2
Status
Issued

Consumables & Implants Readiness

ItemStoreAvailability
Surgical Gloves (M)OT Store Available
Sutures 3-0OT Store Available
Sterile DrapesOT Store Available
Hip Implant — Titanium (ITM-1005)OT Store Available
Issue from Store

Patient Transfer

Transfer Time
08:50
Transferred By
Ayesha Siddika
Identity Verified
Yes
Condition
Stable
Oxygen
Room air
IV Line
18G, left forearm
Catheter
N/A
Consent Status
Confirmed

OT Admission

Arrival
08:55
Vitals
BP 130/84, HR 80
Consciousness
Alert
Monitoring Status
Connected
Allergies
Penicillin
Checklist Status
Complete

Sign In (before anesthesia — 09:00, Sultana Begum)

  • Patient identity confirmed Completed
  • Procedure confirmed Completed
  • Surgical site confirmed Completed
  • Consent confirmed Completed
  • Site marking confirmed Completed
  • Anesthesia machine checked Completed
  • Pulse oximeter available Completed
  • Allergies reviewed Completed
  • Difficult airway risk assessed Completed
  • Aspiration / blood-loss risk assessed Completed

Time Out (before incision — 09:28, whole team)

  • Team introduction completed Completed
  • Patient identity confirmed Completed
  • Procedure confirmed Completed
  • Site confirmed Completed
  • Antibiotic prophylaxis given Completed
  • Critical steps reviewed Completed
  • Expected blood loss discussed Completed
  • Equipment concerns reviewed Completed
  • Imaging displayed Completed
  • Sterility confirmed Completed

Sign Out (before leaving OT)

  • Procedure recorded Pending
  • Instrument count Pending
  • Sponge count Pending
  • Needle count Pending
  • Specimen labeling Pending
  • Equipment problems reviewed Pending
  • Post-op instructions given Pending
  • Recovery plan communicated Pending
Disabled until final counts are entered.

Pre-Anesthesia

ASA Classification
ASA II
Airway
Mallampati Class II
Fasting
Confirmed — 8 hours
Risk Assessment
Low–Moderate
Anesthesia Plan
General anesthesia combined with femoral nerve block
Anesthesia Type
General + Regional (Combined)

Intra-Operative Monitoring

TimeBPHRSpO2RRTempEtCO2
09:05122/787299%1436.7°C—
09:15118/766899%1336.6°C34
09:30116/747098%1336.5°C35
09:45 (latest)120/767498%1436.5°C35

Anesthesia Drug Record

DrugDoseRouteCategoryTimeGiven By
Cefazolin2 gIVAntibiotic Prophylaxis09:00Dr. Nusrat Jahan
Propofol150 mgIVInduction09:05Dr. Nusrat Jahan
Rocuronium40 mgIVMuscle Relaxant09:06Dr. Nusrat Jahan
Fentanyl100 mcgIVAnalgesic09:07Dr. Nusrat Jahan
Sevoflurane1.5 MACInhalationalMaintenance09:08–ongoingDr. Nusrat Jahan
View in Pharmacy

Fluid Balance

Input
  • IV Fluids (Ringer's Lactate): 1,200 ml
  • Blood / Blood Products: 0 ml
  • Total In: 1,200 ml
Output
  • Urine: 300 ml
  • Blood Loss (estimated): 250 ml
  • Drain Output: 0 ml
  • Total Out: 550 ml
Net Balance: +650 ml

Surgical Procedure Record

ProcedureStartEndSurgeonFindings
Total Hip Replacement (Right) — Primary09:30PendingDr. Tom AlexanderIn progress — acetabular reaming underway
Pre-Op Diagnosis
Osteoarthritis, Right Hip (Severe)
Post-Op Diagnosis
Pending — recorded at closure
Technique
Posterior approach
Blood Loss
250 ml (running estimate)
Condition at Completion
Pending

Intra-Operative Events

TimeEventRecorded By
09:00Incision site marked and confirmedSultana Begum
09:30Incision madeDr. Tom Alexander
09:42Femoral head excisedDr. Tom Alexander
09:50 (latest)Acetabular reaming startedDr. Tom Alexander

Complications

No complications recorded for this surgery.

Instrument Count

TypeInitial CountIntra-Operative CountFinal Count
Sponge2424 Pending
Needle1212 Pending
Instrument (Hip Set, 42 pcs)4242 Pending

Final counts are recorded here before Sign Out can be completed (Safety Checklist tab).

Consumables

ItemQtyBatchStoreIssue Ref
Surgical Gloves (M)6 pairsB2026-0500OT StoreISS-26-3381
Sutures 3-04B2026-0225OT StoreISS-26-3381
Sterile Drapes1 set—OT StoreISS-26-3381

Inventory is updated automatically on Surgery Completion.

Issue from Store

Implants

ImplantManufacturerModelBatchSerialSizeExpiryPurchase Ref
Hip Implant — Titanium (ITM-1005)OrthoFixHX-500B2026-0611SN-HIP-442352mm2031-06-01PO-26-01044

Permanently linked to this surgical record once Surgery Completed.

Blood & Blood Products

Blood Group
O+
Cross-match
Completed
Units Reserved
2 units PRBC (BB-26-1187 / BB-26-1188)
Transfused
0 units (reserved, not used)

Blood Bank is not yet a live module in this prototype — shown as reference data only.

Specimens

No specimens collected yet. The excised femoral head will be sent for histopathology at procedure closure.

Collected Labeled Verified Sent to LIS Result Received
Send to Lab

Post-Operative Record

Final Diagnosis
—
Procedure Completed
—
Condition
—
Drains / Catheters / Dressings
—
Post-Op Medications
—
Diet / Activity / Follow-up
—
Post-Op Medications (available after completion)

PACU Record Not Started

Arrival Time
—
Consciousness / Airway / O2
—
Pain / Nausea / Bleeding
—
Drains / IV Access
—

Patient has not yet arrived in PACU. No observations recorded yet.

PACU Discharge Criteria

  • Stable vital signsNot Assessed
  • Adequate oxygenationNot Assessed
  • Consciousness appropriateNot Assessed
  • Pain controlledNot Assessed
  • Nausea controlledNot Assessed
  • Bleeding controlledNot Assessed
  • No acute complicationNot Assessed
  • Physician clearanceNot Assessed

Post-Operative Handover

Handover will be completed after PACU discharge criteria are met. Fields (patient identity, procedure, diagnosis, anesthesia, intra-op events, blood loss, fluids, drugs, drains, lines, specimens, implants, complications, post-op orders, monitoring requirements, sender, receiver, date/time) will populate then.

OT Charges

ChargeAmount
OT Room Charge$350.00
Procedure Charge$2,200.00
Surgeon Fee$1,500.00
Assistant Fee$500.00
Anesthesia Fee$600.00
OT Nursing Charge$200.00
Consumables (running)$180.00
Implants$3,200.00
Equipment Charge$150.00
Blood Products$0.00 (reserved only)
Total (running)$8,880.00

Final invoice generated after Surgery Completion.

View Invoice