Patient Care Part 1

ADMISSIONS

The decision to admit a surgical patient to the hospital is made in the following manner:

ELECTIVE ADMISSIONS

The decision for elective admission is made in the clinic or during a previous hospitalization. All arrangements for admission including financial clearance and medical clearance are made prior to the date of admission. Elective admissions are admitted to the floor after processing in the Admitting Office.

Prior to admission for elective procedures, the diagnosis is explained and the procedure is discussed in detail with the patient.

STANDARD WORK SHEET

Operation:  Ambulatory Surgery Clinic

Process:  Provider  

STEP	Description/Trigger	Image/Key Point/Reason	Who
1	After the provider has decided the patient needs an operative procedure, the surgeon requests for OR time on QuadraMed.		Provider
2	Provider completes PAT package on QuadraMed		Provider
3	Provider checks insurance status of patient on customer service form		Provider
4	Order procedure(s) in QuadraMed	Include all equipment needs in the order. Order radiology, labs, EKG, etc. in QuadraMed (if applicable)	Provider
5	Procedure that requires needle localization	A separate order should be placed in QuadraMed to be forwarded to Radiology work list	Provider
6	Obtain consent forms packet	Instruct patient to fully complete the Ambulatory Surgery Patient Data Form	Provider
7	Emboss all consents
8	Get available RN to witness consent signature	If RN is unavailable, other clinical staff members can act as witness	Provider, RN
9	Complete write-up on patient in QuadraMed		Provider
10	Excuse patient to waiting area to be discharged by the RN	Refer to patient communication script	Provider
11	Put forms (consents, data sheet, discharge instructions, prescriptions, laboratory, and radiological tests, etc.) in Discharge Box 1		Provider
12	Any changes in case status must be submitted no later than 12 noon at the 48hr mark (prior to surgery date)		RN
	Uninsured Patients   After completing the PAT package as in #4, Nurses send patient to financial service counsellors for financial clearance		Patient
14	Patient only goes to PAT after he/she has been financially cleared and called back by PAT staff.		Patient

1. The risks and benefits of the procedure
2. Alternative options that are available including the risks and benefits of the alternatives
3. If the procedure is urgent or non-urgent
4. Need for blood/blood products - This is explained to the patient even if the patient is having a minor procedure e.g. breast biopsy where transfusion may be a remote possibility.
5. The type of anesthesia needed for the procedure including the risks and benefits and alternatives including the risks and benefits of the alternative.
6. Patient’s rights
7. Informed consent is then signed by the patient, the parent or person who is a medical proxy

All diagnostic data including chest x-ray, EKG and blood work are recorded in the admitting history and physical. DVT risk assessment and appropriate prophylaxis must be documented.

A summary of the patient's condition is written and the diagnoses recorded. A plan of treatment is outlined and discussed with the patient and the appropriate surgical attending and recorded in the EMR.

Prior to elective admission, the patient is medically as well as financially cleared.

The surgical attending is notified and approves the elective admission at least 24 hours prior to the admission.

The history and physical examination form can be completed by an extern, a physician assistant, an intern or resident and must be countersigned by the surgical attending responsible for the patient in the EMR.

EMERGENCY ADMISSIONS

The decision for emergency admission is made by the clinic staff when a patient seen in the regular clinic, meets the criteria for emergency admission.

 

The decision to admit a patient seen in the Emergency Department is the responsibility of the emergency room attending staff. The surgical resident on duty does not participate in this decision, unless requested on a consultation basis, by an Emergency Department attending.

If there is an emergency admission, the chief resident and the attending on-call are promptly notified. If a patient needs an emergency admission and/or operation, the diagnosis and the procedure are discussed with the patient and a detailed review of history and physical exam obtained. All diagnostic studies including x-ray and EKG are completed in the emergency room and DVT risk assessment and prophylaxis to be given documented prior to admission.  All information is recorded in the EMR.

 

Some emergency admissions are taken directly to the operating room. If a patient needs to go to the operating room, all x-ray requests are entered in the EMR and the results reviewed and recorded. All the necessary blood work and urinalysis are checked prior to the patient's arrival in the operating room.

 

Informed consent for operative procedure that details the risks, benefits and alternatives and the risks and benefits of the alternative is obtained in the Emergency Department by the surgical resident.

 

A history and physical examination and a pre-operative note are written in the EMR.

 

ORDERS

Routine orders are entered in the computer each day before 10:00 a.m.

Admission orders are entered in the computer as soon as the patient gets to the ward.

 

Admission/Routine Orders entered in the computer include the following:

 

 

OLD CHART