Patient Care Part 1


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


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.


Operation:  Ambulatory Surgery Clinic

Process:  Provider  



Image/Key Point/Reason



After the provider has decided the patient needs an operative procedure, the surgeon requests for OR time on QuadraMed. 




Provider completes PAT package on QuadraMed 




Provider checks insurance status of patient on customer service form




Order procedure(s) in QuadraMed



Include all equipment needs in the order.

Order radiology, labs, EKG, etc. in QuadraMed (if applicable)




Procedure that requires needle localization

A separate order should be placed in QuadraMed to be forwarded to Radiology work list 



Obtain consent forms packet

Instruct patient to fully complete the Ambulatory Surgery Patient Data Form



Emboss all consents




Get available RN to witness consent signature

If RN is unavailable, other clinical staff members can act as witness

Provider, RN


Complete write-up on patient in QuadraMed




Excuse patient to waiting area to be discharged by the RN

Refer to patient communication script



Put forms (consents, data sheet, discharge instructions, prescriptions, laboratory, and radiological tests, etc.) in Discharge Box 1




Any changes in case status must be submitted no later than 12 noon at the 48hr mark (prior to surgery date)




Uninsured Patients


After completing the PAT package as in #4, Nurses send patient to financial service counsellors for financial clearance




Patient only goes to PAT after he/she has been financially cleared and called back by PAT staff.



In discussing the procedure the following are stressed:
  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
A detailed history of the patient's present condition is obtained - including the chief complaint, past medical history including previous hospitalization, childhood or adult illness, any major trauma.
Family and social history that includes any age related issues, genetic related diseases, education, marital status, tobacco, drug and alcohol use is obtained.
Allergies and medications used by the patient are recorded. Indications for each medications are reviewed and a medication list is developed. A problem list is developed and entered into the Electronic Medical Records (EMR).
The physical status, mental and functional status of the patient are assessed.

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.


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.



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:

The actual diagnosis is noted


The ward, surgical service and attending in charge of the patient are included in the admission note by the resident.


The patient's general condition (good, fair, critical or poor) is specified.
Allergies to specific medications are recorded.


All medical records of previous admission(s) must be obtained from the record room or computerized record on admission.
The patient is ordered N.P.O., or full liquid, soft, regular or special diet (cardiac, renal, diabetes) enteral feeding or hyperalimentation
Restricted, out of bed, mobilize as tolerated, deep breathing are ordered
BP, P, R, T - are ordered with the necessary frequency.
IV fluid composition and rate are ordered.
INTAKE AND OUTPUT - Is ordered if indicated
Measurement of fluid intake - P.O., IV.
Measurement of fluid losses - NG, urine, fistula, etc.
DAILY WEIGHTS – are ordered if indicated
Significant weight gain or loss is noted to help adjust fluids or diuretic.
Education and Plan of Care Education and plan of care of the patient must be entered in the computer on initial admission and updated in the computer when there is a change in management plan of the patient.
DVT Risk Assessment Form must be completed on admission on line and all patients who meet the criteria for DVT prophylaxis must be started on prophylaxis. This is a JCAHO requirement
Non approved abbreviations should be checked on line.
Abbreviations should be avoided.
Orders for routine tests
Orders for specific tests
Patient's previous medications and Therapeutic medications must be reconciled,
Orders for narcotics and other drugs are automatically ordered doing 48 hours
Post-operative PCA Pumps are recommended
NG suction or lavage
Catheterization of urinary bladder
Monitoring of drainage from chest tube, or any drains
Monitoring of urine output, CVP, Swan-Ganz, etc
Stat orders are directly communicated to the nurses and entered in the computer.
Special orders, e.g., NPO, bowel preps, etc., are explained to both patient and nursing staff.
To insure that patients receive medication as ordered house staff routinely check administration on the computer.
The pre-operative note written in the EMR should include at the minimum the following:
Pertinent history and physical examination finding
History and Physical Review
Date of last history and physical
Pre-operative Diagnosis
Proposed Procedure (s)
Indication for Surgery
Problem lists of patient
Name of resident
Name of attending
Attending note