DAY SURGERY (ADULT) GENERAL ANAESTHETIC … · make decisions around their care/treatment? Yes: No...

Preferred Name:

Daytime/Work tel no:

Evening tel no:

Mobile no:

Fitness to work certificate:

Next of Kin/Contact:Relationship:Aware of admission: YES

NO

Tel no (NOK):Mobile no (NOK):

Religion: Special Dietary Requirements:

Consultant: Name of person providing transport home:

Tel no:

Mode of transport:Planned Operation/ Procedure:

Travel time to homeProvisional Admission Date:

Date of Admission: DD/MM/YYYY

DD/MM/YYYY

Cancelled- reason: Name of person providing 24/48 hour care:

If specific requirement chosen, ensure that consent is completed and filed

NONEPreferred language (if not English):

If yes,state action taken

Interpreter required? YES NO

IC Alert

0 1 2 3 4 5Allergies or sensitivities Yes No

Method of admission Intended ManagementSource of admission Ethnic Group

NOYES

DAY SURGERY (ADULT) GENERAL ANAESTHETIC CLINICAL INTEGRATED DOCUMENT (CID)

of 22

PLEASE DO NOT WRITE IN THIS BOX

Health Records: Charts and Special Shhets

UID:DSOGENASBC01

Clinical Integrated Document (CID) general anaesthetic operations day surgery V1 Approved by Document Approval Group: Sep 12

Review date: Aug 15

Print Name Job Title Location/Bleep Signature Initials

section. Initials can then be used when recording care. All members of staff who are using this care pathway should use black ink and complete this

SIGNATURE RECORD Patient name: .................................................................NHS no: .........................................................................Hospital no: ....................................................................DOB: ..............................................................................

Please affix patient ID label within this box


Review date: Aug 15 of 22Health Records:

Charts and Special ShhetsUID:DSOGENASBC01

Statement of Consent to share information with other service providers: (Please tick all boxes that apply) I agree that the information provided in my assessments may be shared with other agencies/service providers who may contribute to my care and for use in clinical audits I understand that: - This information will be used for providing a service or care to me - I may withdraw my consent to share information at any time and this may result in a reduction of services being available - I have the right to restrict what information may be shared and with whom, but this may affect the provision of services that i receive - My information will be held securely on paper and on computer in accordance with the Data Protection Act 1998 I have made the following restrictions (if applicable): I give consent for information to be given to my next of kin and/or other named person Have you received a copy of the leaflet Protection and Use of Information? YES NO Signature: Print: Date: DD/MM/YYYY Staff signature: Date: DD/MM/YYYY

STATEMENT OF CONSENT TO SHARE Patient name: .................................................................NHS no: .........................................................................Hospital no: ....................................................................DOB: ..............................................................................



Review date: Aug 15 Health Records:


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We are sorry we cannot accept responsibility for loss or damage to items that you do not give to us to be locked away for safekeeping

Please tick

The above disclaimer has been read to the patient and the patient property policy has been explained.

Patient’s ID Label _________________________________________________________

PATIENT'S PROPERTY

1. If NO please sign this declaration: Patient's Signature.............................................. Print Name.......................................................... Staff Signature.................................................... Print Name.......................................................... Date.......................Time.....................................

3. Patient has property of value but does not wish this to be locked away. Patient's Signature.............................................. Print Name.......................................................... Staff Signature.................................................... Print Name..........................................................

3. Patient has property of value and wishes this to be placed for safekeeping. Valuables placed in blue bag and then in safe located................................................................................... Receipt No of blue bag here...........................................................................................................................

DD/MM/YYYY HH:MM

Patient name: .................................................................NHS no: .........................................................................Hospital no: ....................................................................DOB: ..............................................................................



Review date: Aug 15 Health Records:


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SOCIAL HISTORY

Marital/Partnership Status

Single

Widow/er

Married

Civil Partnership

Divorced

Cohabiting

Separated

Lives:Alone With spouse/partner Other

Type of housing:....................................

Carer

Is the patient a carer?

*Yes

No

If *yes, has the patient been offered a referral to carers' support services?

NoYes Declined

If *yes, have arrangements been made for the patient's dependant?

NoYes

Cared For

Does the patient have a carer? No*Yes

If *yes, carer's name and contact details:

Does the patient's carer require an overnight stay?

If yes, booked with site management?Has the patient's carer been offered a referral to carer's support services?

NoYes

NoYes

DeclinedNoYes

Deprivation of liberty assessment

Do the deprivation of liberty safeguards apply to this patient?

If yes, does the care planned for this constitute a deprivation of liberty?

During this assessment have concerns been raised about the persons ability to make decisions around their care/treatment?

Yes No

If yes to any of the above, document action taken:

Miscellaneous Information:Patient has an organ donation card/on organ donation register?

Patient has an advanced directive/living will

Patient has a Treatment Escalation Plan (TEP)

NoYes NoYes

NoYes NoYes

NoYes

Patient would like further information

Medical team aware

Evidence seen

Medical team awareNoYes NoYes

Support services: None Home Care Meals on wheels Personal/care assistant District nurseLink with specialist nurseSocial Worker/Care Co-ordinator:




Review date: Aug 15 of 22Health Records: Charts and Special Shhets

UID:DSOGENASBC01

SURGICAL/MEDICAL HISTORY

Medical History Previous Operations

Allergies/Sensitivities Reaction

Drugs

Latex

Food

Other

Drugs including complimentary remedies/inhalers/contraceptive pill

Dose Stop - details

Anticoagulant .............Days Last INR.............

Medication






Pre-op Anaesthetic Screen / Systems Review

SYSTEMS REVIEW NO YES COMMENTSCardiovascular Heart disease/murmur/MI Chest pain/angina: Palpitations/blackouts Hypertension Rheumatic fever Pacemaker CVE/TIA DVT/PE

................................................................................................................................

................................................................................................................................

Respiratory Asthma Bronchitis TB or other chest disease Breathlessness: On exertion at rest / Orthopnoea / PND

................................................................................................

................................................................................................

Gastrointestinal Indigestion/heartburn Dysphagia Nausea/vomiting Abdominal pain PR blood/mucus Bowel changes Appetite/weight changes Jaundice/hepatitis (status)

................................................................................................................................

................................................................................................................................

Genitourinary Haematuria Nocturia Frequency Urgency Hesitancy Poor stream Menorrhagia

................................................................................................................

................................................................................................................

Renal Kidney problems

...............

...............

CNS / Neurological Epilepsy/fits Weakness/numbness: arms / legs Migraines

................................................

................................................

Haematological Anaemia/other blood disorder Excessive bruising/bleeding

................................

................................

Endocrine Diabetes Thyroid disease

................................

................................

Musculoskeletal Rheumatoid arthritis

.................

.................

Smoker: NO EX YES

If YES, how much per day:

If EX, year stopped:

Alcohol: Units / Week:

Clinical Integrated Document (CID) general anaesthetic operations day surgery V1

Approved by Document Approval Group: Sep 12Review date: Aug 15


UID:DSOGENASBC01 of 22




Review date: Aug 15



Physical Examination:

Completed by: Designation:

Pre-op ObservationsWeight Height BMI Urinalysis: Action:

BP Pulse Sp02 (if indicated) CBS:

Women: - (child bearing age only) LMP: Could you be pregnant? YES NO

Pregnancy test required? Risks of surgery/pregnancy discussed?

Pre-op Airway Assessment (please circle answers)

Details:

Airway assessment: YES NO Neck / Jaw: YES NODetails:

Mallampati:

Teeth: Crowned Capped Loose

Dentures: Top Bottom

Patient has: Contact lens Hearing aids Implants Prosthesis Disabilities

Details:

Jaundice Anaemia Cyanosis Clubbing Lymph Nodes Oedema

CVS JVPApex beatHS

RS

Diabetic foot assessment required? Yes If yes, see separate form

Peripheral pulses

AS

Has the patient or any family members had any previous anaesthetic problems? YES NO



Results Checked Date............................... Signature/Initial...............................

Additional Information / Action taken (if required)

INVESTIGATIONS

DD/MM/YYYY

Tick if requested Results Abnormal Tick if

requested Results Abnormal

Hb G&S crossmatch .....................units

WCC AAT

FBC Plat Bili

LFTs Alk Phos

Albumin

INR

APTR Glucose

Coag. Screen Fibrin HbA1c

PT time TFTs

Control time CRP

Urea ECG

U & E Na X-ray

K Photo

Creat Other





UID:DSOGENASBC01

Pre-op Information given to patient:

Goal Yes No (reason for variance)Admission procedure explained (including all of the following: what to bring in, where to go, ward if known, visiting times, fasting, time and date of procedure)Hospital property of value policy explainedOperation to be performed discussed, including specific risks associated with procedurePost-operative limitations discussedGeneral risks associated with surgery explained verbally, including: Infection/bleedingAnaesthetic risksDVT/PE Risk assessment completePain management (pain scoring, post op pain relief, drugs on discharge)Chest-related problems

Confirmation about changes in medication discussed

If any please state:

Advised to contact the hospital if any changes between pre-assessment and admissions e.g. pregnancy, new illness, infection, change in condition

Patient given opportunity to discuss concerns, ask questions

Other information given

Pre-Assessment Outcome / Communication

Medication Changes:

Anaesthetic Review:

Surgical Review:

Other problems:

Pre-Assessment Outcome: Planned for surgery Surgery deferred

Assessment performed by: Signature: Status: Date:DD/MM/YYYY


Review date: Aug 15





Admitting Nurse: Signature/Initial:

Date:

Additional Information

Signature/Initial: Date: DD/MM/YYYY

ADMISSION CARE PLAN

Achieved Action Initial

Admit and orientate to unit

Explain procedures/medications

Seen by Surgeon

Seen by Anaesthetist

Discharge discussed

Answer any questions

Patient trolley/ O2 preparedHas the patient or any other member of the

household had diarrhoea/vomiting in the last 48hrs

Has the patient bathed/showered prior to admission

OBSERVATIONS ON ADMISSION Temp Pulse Resp/SpO2 BP

Peak flow CBS

Waterlow scale Manual Handling

LMP: Date Pregnancy test: neg/pos

Blood Group Anti D N/A Ordered

DD/MM/YYYY





UID:DSOGENASBC01

Surgical Safety Checklist

Ward…………………………..... Consultant………………...................………Date…………..…………..DD/MM/YYYY

Operation…....................…………………………………………………………………………..……………

Anti-embolism stockings in situ Yes N/A

Jewellery, hair clips, make-up, nail polish removed Yes N/A

Two identification bands Yes

Preparation for Surgery guidance on preoperative daily medication administration has been followed

Yes No N/A

If no, please explain why

Allergies Yes No If yes,

please state

Infection control alert Yes No If yes,

please specify

If yes, please phone Theatres and advise Theatres contacted: Yes

Ward preparation

Sign Out from ward

Patient fasted for six hours [food] Yes N/A

Infant fasted for four hours [breast milk] Yes N/A

Patient fasted for two hours [clear fluid] Yes N/A

Operation site marked and confirmed as correct using notes and consent form Yes

Pregnancy test negative Yes

Test declined/states not pregnant Yes If signature of patient required above

Check notes have correct labels Yes

Consent form completed including correct label Yes

Patient identity and surgery confirmed by patient, notes and bands Yes

Child and Women’s HealthPR medication Yes

Swabs (Gynae) Yes

Bladder empty Yes

Additional information Yes No (e.g. Retained prosthesis, Waterlow >10,disabilities, communication issues, etc)

Please state

Sign outpractitioner name:

Signature:





UID:DSOGENASBC01

TheatreSign In to anaesthetic roomPatient identifies him/herself Yes N/A

Confirm operation with patient/carer Yes N/A

Both identity bands checked with notes Yes

Theatre list correct Yes

Consent form completed Yes

Operation site marked and confirmed as correct against notes and consent Yes N/A

Stop Before You Block check completed Yes N/A

Notes and labels checked and correct Yes

Check in practitioner name: Signature:

Time Out – before incisionIf undertaken in the anaesthetic room the scrub practitioner should confirm side and surgery with the surgeon independently.

Check patient identity Yes

Check consent correct Yes

Confirm operation planned Yes

Demonstrate side on imaging Yes N/A

Did the team

consider

Appropriate antibiotics(MRSA alert/risk considered) Yes

Thrombo-embolic precautions Yes

Blood cross matched Yes

Allergies Yes

Anaesthetist performing Time OutSurgeon performing Time OutScrub practitioner performing Time OutCheck in Signature:practitioner name:

Sign Out (to be said out loud before the patient leaves the Theatre)Has procedure been recorded? Yes

Side of operation agrees with consent form Yes N/A

Instrument counts correct? Yes

Specimens processed as per Specimen Policy Yes No specimens

Formalin added? Yes N/A

Clinically significant blood loss? Yes No

Have the key concerns for recovery and post-op management plan (including antimicrobials) been discussed?

Yes

State any equipment problems identified that need to be addressedSign out practitioner name: Signature:




Review date: Aug 15



THEATRE RECORDDate: / /

General anaesthetic

Anaesthetic

Spinal

Paravertebral block

Nerve block

Epidural

Topical

Local anaesthetic used

Sedation

Throat packsNo throat pack Tampons Ribbon gauze

Signed on removal ____________________________

YYYYMMDD

PositioningSupineLithotomy

Arms across chest

Neck extended

Left lateralLeft arm extended

Arm by left side

Legs abducted

Right lateralRight arm extended

Arm by right side

Prone

Maquet tableHands padded, tucked under pelvis

Arms in "stick'em up position"

Self supportingPositioning aids and pressure relieving equipmentGel padArm guttersHeel cups'L' shaped arm supportsHorseshoe/head ringLateral supportsArm tableOther

RollOrthopaedic traction tableLithotomy/Allen/Lloyd Davies stirrupsMaquet lithotomy supportsDouble arm boardMontreal mattressVacuum patient positioner

Traction tongsMayfield headrestAnti-thrombotic deviceVaricose vein leg boardPillowsSand bagCarter Braine supports

_____________________________________________Other equipment usedTorniquetTime ON____________________ Time OFF___________________ Total time___________________Skin protection used_______________________Pressure____________________Signed____________________________________ Check site post procedure VA

HH:MM HH:MM HH:MM

DiathermySite shaved:Monopolar NoYes

Bipolar Plate site:_____________________________ Condition of site post procedure VA

Prevention of hypothermiaTheatre temperature raisedInsulation coversBair Huggers

Skin preparation usedClorhexidine spirit + red stainingIodine alcoholicIodine antiseptic Clorhexidine clear spirit

OtherTraveseptClorhexidine acetate






Surgery performed:

Local anaesthetic infiltration: Time:

Specimens: Number:

Skin stored:

HH:MM

Urinary catherisationIntracystic irrigation Catheter bag Suprapubic Urometer

2 way / 3 way

Affix catheter label here

Packs/otherCheek packs x B.I.P.P. 1/2" or 1" Netcell/Merocel nasal packs

Silastic sheet

Other

Packs left in + site______________________________________________________________________________________

Wound closureVicryl Maxon Staples Prolene P.D.S.

Novafil Monocryl Nylon Silk Hystocryl glue

Other

THEATRE RECORD (continued)

Date: / / YYYYMMDD






Date: / / YYYYMMDD

DrainsMedinorm 16Ch, site: ______________ Robinson 30Ch, site: ______________

Medinorm 12Ch, site: ______________ Robinson 20Ch, site: ______________

Medinorm 10Ch, site: ______________ Robinson 18Ch, site: ______________

Medinorm 8Ch, site: ______________ Exudraine, site: ______________

Concertina 6Ch, site: ______________ Corrugated/Yates, site: ______________

Nephrostomy, site: ______________

Opsite post op dressing Kaltostat/Mefix/microfoam Vista drops/Sofradex drops

Suture strips Proflavin wool with silk tie over Nasal bolster Lyofoam/Reston

Foam Jelonet, Telfa, gauze, Velband and crepe Stockinette and gauze

P.O.P./FULL/backslab Achromycin cream/chloramphenicol ointment Stockinette, Velband, crepe

Micropore tape Hydrocortisone 1%/soft yellow paraffin Tegaderm/Mepore

Other

ressingsD

Swab, needle and instrument count

1st scrub practitioner Circulator

2nd scrub practitioner Circulator

Comments

Variance trackingInitials, date, time Variance and action taken (use variance continuation sheet if required)

THEATRE RECORD (continued)Patient name: .................................................................NHS no: .........................................................................Hospital no: ....................................................................DOB: ..............................................................................




UID:DSOGENASBC01

THEATRE RECORD (continued)

Barcodes and prostheses:

Date: / / YYYYMMDD Patient name: .................................................................NHS no: .........................................................................Hospital no: ....................................................................DOB: ..............................................................................





I.V. Cannula(e) as per VIP sticker

Post-op Recovery Care - For minor operations/proceures & day - case patients A=Achieved: V=Variance: NR=Not Requested: NA=Not ApplicableDocument variances and action taken Date:

RespiratoryUnconscious time............................ Conscious time............................ Orientated time (normal for patient).................

Airway maintained by: Own airway Airway adjunct:.................................................... Removed at..............................

Colour, Resps,Sp02 satisfactory A V Oxygen therapy at......L/min until............

Oxygen therapy continued at.........L/min as prescribed

VA

VA

CardiovascularHeart rate/BP/Temperature satisfactory and recorded on anaesthetic chart* *if patient did not receive an anaesthetic, record observations belowTime.......... BP: / Pulse: Temp: RR: Sp02: on..........L/min EWS:

EWS:on..........L/minSp02:RR:Temp:Pulse:Time.......... BP: /

EWS:on..........L/minSp02:RR:Temp:Pulse:Time.......... BP: /

Patient ComfortAnalgesia given in theatre: Y N Refer to: Anaesthetic chart Theatre record Drug chart

Site of local anaesthetic injection satisfactory A V V

V

A

A

Analgesia effectiveNA

Patient aware more analgesia available Further analgesia given NR Y

............................................................................................................................................................................................................................................................................

............................................................................................................................................................................................................................................................................

............................................................................................................................................................................................................................................................................

............................................................................................................................................................................................................................................................................

Gastrointestinal/Fluid management

Care as per I.V. policy A V

A

Nausea/vomiting prophylaxis given in theatre Y N

AI.V. infusion as prescribedVA V NA

Effective anti-emesis V NA Diabetes Y N: Interventions: CBS......................mmols at.............

or refer to diabetes chart Y N

Integumentary/operative careOperation site(s) 1)...................................................................2).....................................................................Intact? VA

No evidence of bleeding

Wound drain Drain release time............drainage........mls at.............(more than one drain use major care-plan)

PV loss satisfactory

NY

NAVA Nasal bolster?pack insitu NY Neurovascular Obs intact VA

Limb..................................elevated by.......................... NA Specialist post-op obs chart commenced NY NR

Pressure areas satisfactory

Manual handling assessment complete

VA Nursed in...............................................position Waterlow score.....................

Intervention required NY VA

Genito-urinaryContinent of urine VA Urine passed in recovery NY Urinary catheter in situ NY

VA

VA

DD/MM/YYYY

HH:MM

HH:MM

HH:MM






DischargeRecovery discharge criteria met A Time: EWS (<2)....................... See EWS chart Above

Discharge TTO form complete Y N Operation Note written/typed Y N

Recovery StaffRecovery practitioner signature..................................................................................................................

Recovery practitioner signature..................................................................................................................

Time of handover...................................

Handover of care to ward staff - Time........................Recovery practitioner sign............................................................................. Ward practitioner sign................................................................

Patient Property NY .........................................................................................................................................................................

Property labelled VA Returned to patient To ward with patient

Recovery Care - Variance Tracking Date

Date, Time and initials DD/MM/YYYY HH:MM Variance and action taken

HH:MM

HH:MM

DD/MM/YYYY



Approved by Document Approval Group: Sep 12Clinical Integrated Document (CID) general anaesthetic operations day surgery V1


UID:DSOGENASBC01

POST OPERATIVE CARE

Ward:

Estimated time home: Relative/carer contacted Yes No

TimeBPPulseTempRespSpO2EWS recorded as clinically indicatedPain Pain scores (1-10)Wound checked

PV/PR loss amount

Alert & orientated Yes/NoOral fluids/diet offered

Passed urineSteady gaitSeen by physioCannula in situ VIP scoreIV fluids in progress

Manual handling Risk Assessment

Signed

Further information e.g. diabetic management

Signed........................................................





UID:DSOGENASBC01

DISCHARGE

Yes No Details/Actions

Patient dressed

Observations within patients normal limitsWound PV/PR loss checked/acceptable

Dressing/Suture Advice

Passed Urine

Cannula removed VIP SCORE

Verbal Advice

Written Advice

Emergency contact numbers given to patient

Fitness for work certificate

Practice/District Nurse Referral

Copy of Consent

GP Letter

TTO & Advice

OPD

Dressing Clinic

Mobility on discharge

(please circle)Independent Needs 1 person Needs 2 people Dependent As prior to

admission

Discharge Date: Discharge nurse Signature/initial:

Time HH:MMDD/MM/YYYY





UID:DSOGENASBC01

Further discharge information - including transfer to other units - follow up

Date Signature/InitialDD/MM/YYYY






DAY SURGERY (ADULT) GENERAL ANAESTHETIC … · make decisions around their care/treatment? Yes: No...

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Transcript of DAY SURGERY (ADULT) GENERAL ANAESTHETIC … · make decisions around their care/treatment? Yes: No...