The surgical record

A consistent clinical order

The narrative appears on the first page, before the detailed tables. The record uses professional clinical wording guided by College of Veterinarians of Ontario record-keeping language.

1. 1. Patient, procedure and team

   Species, selected procedure and team information retain their source markings.

2. 2. Narrative summary

   A case summary written from record entries. Each sentence is checked against its supporting facts.

3. 3. Indication and preoperative assessment

   The recorded reason for the procedure and the stated preoperative context.

4. 4. Operative report

   Findings and procedural steps supported by the captured evidence.

5. 5. Closure

   Layers with their recorded material, size and pattern. Missing details remain visible for review.

6. 6. Anaesthesia

   Medications by phase, with dose, route and site; monitor vitals, spoken vitals and monitoring notes.

7. 7. Outcome and plan

   Post-operative status, discharge medication, restrictions and rechecks, where documented.

8. 8. Record

   Approving veterinarian, record number, fingerprint and software identification.

Read each source marking

Not documented: information was not captured for that field. From selection: chosen when the case began. Recording clock: a time supplied by the device clock. Also stated: relevant information retained under its section when there is no dedicated field.

Evidence stays with the entry

Spoken facts retain the quotation, speaker, time and interval. Monitor readings retain their source image region. Selected information and device-clock values are marked separately. The timeline preserves the spoken wording.

Review before approval

The draft lists fields still to complete, the closest relevant words, possible mishearings and conflicting values. Facts are not silently overwritten. An evidence-supported resolution records its reason; unresolved conflicts remain for the veterinarian.

The surgeon approves with their name and time and may add a comment. The approved copy removes the draft review band. Direct entry of missing clinical values on the appliance is not available; those fields are completed in the practice system after export.

Professional wording, retained evidence

Wording checks preserve the fact, its specificity and its numbers. A rewrite that fails verification retains the original wording. The narrative is checked sentence by sentence against record entries.

Explore the record

The document structure is described here. For a walkthrough of current outputs, contact Vetucate.