ER Surg Proforma
2
Hosp # DOB Gender Initial Assessment Management Date of admission Y Day of admission Time decision to opera Time of admission Type of operation Referral source Date of operation Days feature presentatio Day of operation Presumed diagnosis Time of operation Surg/Delg Major Operation Y N Mortality risk discusi Y Y N Capacity recorded Y Critically ill Y N Consent recorded Y Death Y N Unplanned Reoperation Y N Delay in operation Y Considered ITU/ ITU'ed Y N Reason for delay Urgency class Record Time of : Later Decision Not to Opera 1st referral Date of decision 1st surgical referral Reason SpR review Expected Discharge dat Y Consultant review Outcome Outreach review Pls Circle Death (<8 daysTransfer ITU review CT request Death within 30 days Y CT report out Reason of death Definitive management plan documented Consultant Presence (pls circle) Operation between 10 pm- 8 am
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Transcript of ER Surg Proforma
Hosp #DOBGender
Initial Assessment Management
Date of admission Y NDay of admission Time decision to operateTime of admission Type of operationReferral source Date of operationDays feature presentation Day of operation
Presumed diagnosis
Time of operation
Surg/Delg Anaest/DelgMajor Operation Y N Mortality risk discusion Y N
Y N Capacity recorded Y NCritically ill Y N Consent recorded Y NDeath Y NUnplanned Reoperation Y N Delay in operation Y NConsidered ITU/ ITU'ed Y N
Reason for delayUrgency classRecord Time of : Later Decision Not to Operate
1st referral Date of decision1st surgical referral ReasonSpR review Expected Discharge date Y NConsultant review OutcomeOutreach review Pls Circle Death (<8 days) Transfer Reoperate RecoveryITU reviewCT request Death within 30 days Y NCT report out Reason of death
Definitive management plan documented
Consultant Presence (pls circle)
Operation between 10 pm- 8 am
