The pre-operative diagnosis and the post-operative diagnosis are often the same. When they're not, the discrepancy is the most clinically important data point in the case record. A right lower quadrant pain presenting as acute appendicitis that comes out of theatre with a post-operative diagnosis of perforated Meckel's diverticulum is a finding that changes the post-operative management, the follow-up protocol, and potentially the family history documentation for first-degree relatives. That divergence lives in the gap between Pre Operative Diagnosis and Post Operative Diagnosis.
The Operative Team and Accountability
Consultant, Surgeon, 1st Assist, 2nd Assist, 3rd Assist, and 4th Assist create the complete operative team record. For medico-legal purposes, for surgical competence assessment in training programmes, and for outcomes analysis by operator, the specific personnel present during each case must be documented. A series of 40 laparoscopic cholecystectomies with a single conversion to open laparotomy is a different performance record depending on whether the same consultant performed all 40 or whether the conversions cluster around specific trainees. The team record makes that analysis possible.
Private/ Charity and Operation Type are the administrative and classification fields that organize the case log by funding category and procedure type. Separately from the clinical record, these fields feed into theatre utilization analysis, cost accounting, and the reporting requirements for charitable or subsidized surgical programmes.
Pre-Operative Documentation
History is the clinical narrative at intake — the presenting complaint, its duration, relevant past medical history, medication history, allergies. PE captures the physical examination findings. Work Up/ Labs documents the investigation baseline before proceeding to theatre.
These three fields serve different functions in the case record. History is the clinical reasoning document — the story that justified the operative plan. PE is the objective findings at the time the decision to operate was made. Work Up/ Labs is the medical fitness assessment — the haemoglobin that determined whether blood products needed to be cross-matched, the coagulation profile that determined whether anticoagulation reversal was required, the ECG and anaesthetic assessment that cleared the patient for general anaesthesia.
Pre Operative Diagnosis is what you went in expecting to find. The gap between that and Intraoperative Findings is what actually happened once the field was exposed. A laparotomy for presumed mesenteric ischaemia that reveals a strangulated femoral hernia with gangrenous bowel has a pre-operative diagnosis, a set of intraoperative findings, a changed Operation/ Procedure from what was planned, and a Post Operative Diagnosis that's different from all of them. Each field is a distinct clinical data point.
Specimen and Histopathology
Specimen and Histopath close the case record with the tissue diagnosis. A cholecystectomy specimen sent to pathology is routine. An incidental finding sent from an ovarian cystectomy — a specimen with unexpected gross pathology that was noted during the procedure — requires Specimen to document exactly what was sent and Histopath to link the eventual pathology result back to the operative record.
Others handles the clinical information that doesn't fit cleanly into any of the structured fields — anaesthetic technique, intraoperative complications, specific equipment used, relevant case notes that don't belong in the standard fields but need to be attached to the case record.
Room Number and ID Number are the administrative identifiers that tie the operative record to the hospital's patient management system and the theatre scheduling system. Date of birth with Age / Sex and Date of Operation complete the patient identification layer.