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

Clinical Integrated Document (CID) local anaesthetic operations day surgery V1 Approved by Document Approval Group: Sep 12Review date: Aug 15

of 14

PLEASE DO NOT WRITE IN THIS BOX

Health Records: Charts & Special Sheets UID: DSOLOCASBC01

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

Clinical Integrated Document (CID) local anaesthetic operations day surgery V1 Approved by Document Approval Group: Sep 12Review date: Aug 15 of 14


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: ..............................................................................




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: ..............................................................................



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:





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





Complete Result Complete Result

FBC ECG

Renal X-ray

Liver USS

Thyroid MRI

Clotting/INR MRSA screen

Hba1c/glucose Photo

Sickle cell Swabs

Blood group/cross match..............units

Urine

Anti D ordered Other

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

Action taken (if required)

INVESTIGATIONS

DD/MM/YYYY




of 14Health Records:

Charts & Special Sheets UID: DSOLOCASBC01

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





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:









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:


THEATRE RECORDDate: / /

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 equipment

Gel 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

OPERATION PERFORMED: Infiltrating and additional drugs used:

Surgeon: Irrigations:

Skin Prep:Chlorhexidine:Pov. Iodine:Other

Aqueous SpiritAqueous Spirit

Skin Closure:Sutures: Absorbable Non-absorbable

Clips Staples Suture Strips Other

Implants: Dressing and Packs:Drains sutured Yes No OtherCatheter type:Specimens x

NameScrub practitionerSwab count circulatorCirculator

Special instructions/ hand over to ward staff

Diathermy site checked Adverse Skin reactionsPre Post Bi-Polar

Signature:

Suture removal in.................................................................daysGP: .......................................................days

Dressing clinic...............................................................

OPD: ..............................................

D D M M Y Y Y Y

VA

NoYes NoYes

___________________________________________

HH:MM HH:MM HH:MM





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:

Post-op Recovery Care - For operations/Procedures using Local Anaesthetic A=Achieved: V=Variance: NR=Not Requested: NA=Not Applicable Document variances and action taken overleaf

Date:

Patient ComfortSite of local anaesthetic injection satisfactoryPatients aware more analgesia availableFurther analgesia given..............................................................................................................................................

Analgesia effectiveFurther analgesia given:

A V ANR Y

VVA

Integumentary/operative careOperation site(s)........................................................................................................................... VAIntact?

VANo evidence of bleeding NYSpecialist post-op obs chart commenced

DischargeRecovery discharge criteria met A Time: Discharge TTO form complete NY

Y NOperation Note written/typed

Recovery Staff

Recovery Practitioner sign.........................................................Ward practitioner sign............................................

Recovery Practitioner signature................................................................................................................................

Handover of care to ward staff - Time:

Patient property NY

Implants/Additional information/barcodes for traceability

Batch no/Implant no:..................................................................................

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

DD/MM/YYYY

HH:MM

HH:MM

HH:MM

HH:MM

HH:MM





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:

TimeDD/MM/YYYY HH:MM






Additional information/variance - transfer / follow - up etc.

Date Signature/InitialDD/MM/YYYY





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

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