Book a procedure, run the pre-anesthetic checklist, capture consent, and sign off take-home prescriptions, all from the Schedule tab of the Surgery page.

app.chartling.io C Chartling CLINICAL Visits & SOAP Surgery Anesthesia Medications & Rx Controlled subs. Surgery › Schedule › Biscuit Biscuit · OVH completed Pre-anesthetic checklist ☑ NPO confirmed (≥8h fast) ☑ Current weight recorded ☑ Pre-op vitals within normal limits ☑ IV catheter placed ☐ Recovery space prepared 7 of 10 items checked Surgical consent Signed Signed by Maria Alvarez (Owner) Aug 26, 2026 · 8:41 AM Take-home Rx Gabapentin 100mg · proposed Tramadol 50mg · proposed Ready to sign off Consent captured · checklist in progress · 2 Rx drafts pending review Sign off surgery scheduled → consented → in_progress → completed → finalized

Surgery is its own page in the sidebar, with two tabs: Schedule (booking, checklist, consent, and take-home prescriptions, covered here) and Anesthesia, the live intra-op monitoring worksheet, covered on its own Anesthesia page. A surgery booking can optionally link to the visit or anesthesia record for the same patient, but neither is required.

Booking, consent, and sign-off are separate permissions

Scheduling a surgery and completing its checklist need surgery.schedule. Capturing consent needs surgery.consent.sign. Signing off (finalizing) needs surgery.sign, a dedicated clinical finalize permission, distinct from surgery.schedule, so a customized permission pack can grant booking rights without also granting authority to lock medications and the controlled-substance log. By default, the Vet, Associate Vet, Locum, and Owner / Admin packs hold all three; Vet Tech and Senior Tech hold none of them by default, so a tech cannot book, consent, or sign off a surgery unless an Admin grants it explicitly.

Scheduling a surgery

From Surgery → Schedule, click New surgery. Pick the patient, name the procedure, and set the surgeon, room, scheduled time, and estimated duration. A surgery can stand on its own or link to an existing visit. If linked, completing it can append a charge to that visit's invoice instead of drafting a separate one.

Pre-anesthetic checklist

Each booking gets a default 10-item checklist covering fasting confirmation, current weight, pre-op vitals, bloodwork review, IV catheter placement, fluids, drawn/calculated anesthetic drugs, monitoring equipment, owner contact reachability, and recovery space. Check items off as staff complete them. There's no minimum-completion gate before you can move the surgery forward or sign off; the checklist is a working record, not a blocking requirement.

Capture the owner's surgical consent by typing the signer's name, their relationship to the patient (defaults to Owner), and the consent text. If your clinic uses a template-driven consent form, link an already-signed form_documents record instead. Either way, Chartling logs a consent event and records the signature into the same signature registry used elsewhere in the app. Capturing consent while the booking is still scheduled automatically advances it to consented.

Consent can't be captured for a cancelled surgery, and can't be re-captured once the surgery is finalized. If something about the procedure changes materially after consent is signed, re-consent before proceeding rather than editing the existing record.

Status flow & completing

A booking moves forward through scheduled → prepped/consented → in_progress → completed, or to cancelled at any point before completion. finalized is not a manual status. It's only set by signing off (below), and once a surgery is cancelled or finalized it's locked; there's no path back.

Marking a surgery completed triggers three best-effort follow-ups that never block the status change itself: an invoice line for the procedure (if the completing user holds billing permission and the surgery hasn't already been billed), a post-op recheck reminder dated off your clinic's calendar day, and protocol-default take-home prescription drafts for the procedure, ready for review.

Take-home prescriptions

Once a surgery is completed, its take-home prescriptions are editable in the Rx review panel. Two ways to populate it:

Every drafted line is proposed, not committed. Review, edit, or reject each one before signing off; nothing reaches the patient's medication record until finalize.

Signing off (finalize)

Click Sign off surgery to finalize. This requires the surgery to be completed, a valid consent event on file (disclosed, not declined), surgery.sign, plus rx.write if any prescriptions are confirmed, plus rx.controlled.dispense if any confirmed prescription is a controlled substance. Finalize is idempotent. Calling it again on an already-finalized surgery just confirms it's done rather than erroring.

Confirmed take-home prescriptions are committed to the patient's medication record, and any confirmed controlled-substance line goes through the same DEA pending-witness ledger as a visit dispense. The entry records drug, quantity, patient, and prescriber immediately, but a second person holding rx.controlled.witness still has to countersign before it's complete.

Finalizing a surgery does not sign the patient's SOAP note

Surgery bookings and anesthesia records are both separate from the visit's SOAP note. Signing off a surgery locks the surgery record and commits its take-home Rx; it doesn't touch the SOAP note, and finalizing a visit doesn't touch the surgery record either. If the same episode of care spans a visit, a surgery, and an anesthesia record, each is signed independently.

FAQ

Can I sign off a surgery before consent is captured?

No. Finalize requires a disclosed, non-declined consent event on the booking. Chartling blocks sign-off server-side if consent hasn't been captured, or was declined.

Who can finalize a surgery?

Anyone holding surgery.sign, which by default is the Vet, Associate Vet, Locum, and Owner/Admin packs. Holding surgery.schedule alone (booking rights) is not enough to sign off.

Does the invoice draft on completion count against my plan the same as a visit invoice?

It's the same invoicing capability described on the Invoicing & payments page. See that page for which tiers include invoicing.

Can a tech run the pre-anesthetic checklist?

Not by default. Completing the checklist uses the same surgery.schedule permission as booking, which the Vet Tech and Senior Tech packs don't include out of the box. An Admin can grant it explicitly from Team & permissions if your clinic wants techs to handle checklist prep.

Something missing? We're always improving these docs.

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