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Many eye care centers run a day surgery service where patients come in on the morning of their procedure and go home the same afternoon. Some procedures (particularly complex retinal surgery or cases requiring general anaesthesia in elderly patients) may require an overnight stay. The inpatient module tracks every admitted patient from the moment they are assigned a bay to the moment they are discharged.

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Before You Start

  • Healthcare Service Units must be set up for your surgical bays, laser rooms, and recovery area (and overnight beds if applicable).
  • The patient must have had a consultation where inpatient admission or a procedure was ordered.
  • You need the Healthcare Practitioner role to create inpatient records.
  • The Nursing User role handles nursing tasks and medication administration.

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Day Surgery vs Overnight Stay

At an eye care center: Use the Inpatient module for Day Surgery patients (assigned to a surgical bay) and Overnight Stay patients. For short procedures in the laser room or minor procedure room, a Clinical Procedure record alone is sufficient.

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Step 1: Admit the Patient

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Order Admission in the Eye Examination

When the doctor decides the patient needs day surgery:
  1. In the Patient Encounter, set the Inpatient Status to “Admission Scheduled”
  2. Submit the encounter
This signals the nursing team to prepare a bay.

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Create the Inpatient Record

  1. Go to Healthcare workspace → Inpatient card → Inpatient Record → New
Inpatient Record form showing patient name, primary practitioner, admission date, expected discharge, surgical procedure, and bay assignment section
  1. Fill in the admission details:

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Assign a Surgical Bay or Bed

  1. In the Service Unit section, click the bay assignment button
  2. The Healthcare Service Unit tree opens - green = Vacant, red = Occupied
  3. Select the appropriate bay (OT Bay 1, Recovery Bay 2, Overnight Room 3, etc.)
  4. Save
The patient’s status on their Patient record changes to Admitted.

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Step 2: Pre-operative Nursing Care

On the day of surgery, the nursing team completes pre-operative preparation:
  1. Go to Healthcare workspace → Nursing card → Nursing Task
  2. Find nursing tasks for today’s surgical patients
  3. For each patient, complete:
    • Pupil dilation (administer mydriatic drops)
    • Blood pressure and blood glucose check
    • Surgical site confirmation (right eye or left eye clearly identified)
    • Consent confirmed and on file
    • IV access established (if required)
    • Antibiotic drops given (e.g., Povidone-Iodine)
Nursing Task list filtered to today's surgical patients showing tasks like pupil dilation, blood glucose check, and site marking

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Step 3: Surgery and Recovery

After the surgical procedure is completed:
  1. The surgeon updates the Clinical Procedure record with operative findings and outcome
  2. The recovery nurse checks and records:
    • Initial post-op vision (light perception or better)
    • IOP post-operatively (if indicated)
    • Wound integrity (no leaking wound, correct position)
    • No immediate complications (hyphaema, iris prolapse, choroidal effusion)
  3. Post-operative medications administered and documented:
    • Antibiotic eye drops (e.g., Moxifloxacin 0.5%)
    • Steroid eye drops (e.g., Prednisolone 1%)
    • Anti-inflammatory drops (e.g., Ketorolac 0.5%)
  4. Eye shield or pad applied as per surgeon’s instructions

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Inpatient Medication Orders

For admitted patients receiving post-operative eye drops or systemic medications:
  1. Open the Inpatient Record
  2. Add medications in the Drug Prescription section
  3. The nursing team sees these as Inpatient Medication Orders
  4. Each dose administered is recorded with the time given
For cataract surgery recovery, typical medication schedule:
  • Antibiotic drops: 4 times a day for 2 weeks
  • Steroid drops: 4 times a day, tapering over 4 weeks
  • Anti-inflammatory drops: 3 times a day for 2 weeks
  • Any additional glaucoma drops if IOP elevated post-op

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Step 4: Discharge

When the patient is ready to go home:

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For Day Surgery Patients (Usually Same Day)

  1. The surgeon or recovery nurse confirms:
    • Vision is as expected
    • No bleeding or wound problem
    • Patient is comfortable
    • IOP is within acceptable range (for cataract surgery)
  2. Post-operative instructions printed and handed to patient:
    • Drop instillation schedule
    • Activity restrictions (no rubbing, no swimming, no bending)
    • When to seek emergency care (sudden pain, sudden vision loss, severe redness)
    • Follow-up appointment dates
  3. Open the Inpatient Record → fill in discharge details:
  1. Submit the Inpatient Record
After submission:
  • Patient’s Inpatient Status changes to blank on their record
  • The bay becomes Vacant for the next patient
  • Total Patients Admitted count decreases

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Healthcare Service Unit Setup for Eye Care

Typical service units for an eye care center:

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Field Guide: Inpatient Record (Eye Surgery)

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Monitoring Day Surgery

  • Total Patients Admitted number card: live count of patients currently in bays
  • Vacant Service Units shortcut: shows available bays for the next patient
  • Inpatient Status chart on Dashboard: breakdown of active, discharged, cancelled

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Troubleshooting

The bay shows as Occupied but the patient was discharged The Inpatient Record may have been saved but not submitted. Submit the record to release the bay. Medication orders for post-op drops are not appearing for the nurse Check that the medications were added in the Drug Prescription section of the Inpatient Record and that the record was saved. The patient’s inpatient status is still Admitted after discharge Ensure the Inpatient Record was submitted (not just saved). Submission triggers the status change.

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Best Practices

  • For cataract surgery days, create the Inpatient Records for all patients at the start of the day - this gives the nursing team a clear view of the surgical list from the morning
  • Always print post-op instructions and hand them to the patient on discharge - verbal instructions are not enough for a patient whose vision may be blurred from the procedure
  • For patients operated under local anaesthesia who drive themselves, inform them they cannot drive the same day - document this conversation in the discharge note
  • Book the Day 1 post-op appointment before the patient leaves the clinic - failed Day 1 follow-up is a patient safety risk after intraocular surgery
  • If an inpatient complication occurs post-operatively, update the discharge note with the complication details and the management plan - this ensures the doctor seeing the patient at follow-up has complete information