Assess Patient's Emotional Status and Anxiety Levels
10
Evaluate Surgical Risk Factors
11
Perform Anesthesia Consultation
12
Approval: Anesthesia Consultation
13
Consent Form Review
14
Approval: Consent Form
15
Discuss Preoperative Instructions with Patient
16
Update Patient's Medical Record with Preoperative Assessment Information
17
Prepare Preoperative Care Plan
18
Communicate Care Plan to Surgical Team
19
Verify that Patient Understands Procedure and Post-Operative Care
20
Ask Patient to Sign Consent Form
Patient Identification Verification
Ensure accurate identification of the patient before proceeding with any preoperative assessments. This task is crucial to prevent any mix-ups or errors in the patient's medical records and treatment. Verify the patient's identity by cross-checking their name, date of birth, and unique identification number with their provided documents. If any discrepancies are found, consult with the patient and the medical records team to resolve the issue.
Verify Preoperative Fasting Status
Confirm whether the patient has followed the necessary fasting guidelines before their scheduled surgery. Proper fasting is essential to minimize the risk of aspiration during anesthesia. Ask the patient about their last intake of food or liquids and cross-reference it with the recommended fasting period. If the patient has not followed the fasting instructions, provide guidance on the revised fasting period or consult the anesthesiologist for further instructions.
1
Less than 2 hours ago
2
2-4 hours ago
3
4-6 hours ago
4
6-8 hours ago
5
More than 8 hours ago
Review and Document Patient's Medical History
Thoroughly examine the patient's medical history to identify any pre-existing conditions, allergies, or previous surgeries that may impact the upcoming procedure and anesthesia. Pay attention to chronic diseases, medications, and any known adverse reactions. Document the findings accurately and notify the surgical team and anesthesiologist about any significant medical history that could affect the patient's safety or treatment plan.
Approval: Review of Medical History
Will be submitted for approval:
Review and Document Patient's Medical History
Will be submitted
Conduct Physical Examination
Perform a comprehensive physical examination to evaluate the patient's overall health status and identify any potential risk factors. Assess vital signs, general appearance, cardiovascular and respiratory function, as well as the condition of specific organs or body systems related to the planned surgery. Document the examination findings accurately and report any abnormalities or concerns to the surgical team and anesthesiologist.
1
General Appearance
2
Cardiovascular System
3
Respiratory System
4
Gastrointestinal System
5
Musculoskeletal System
Review and Document Patient's Medication History
Assess the patient's current medications, including prescription drugs, over-the-counter medications, herbal supplements, and any recent changes in medication regimens. Verify the dosage, frequency, and duration of intake for each medication. Identify potential interactions, allergies, or contraindications that may affect the planned surgery or anesthesia. Document the medication history accurately and notify the surgical team and anesthesiologist about any concerns or adjustments needed.
Approval: Review of Medication History
Will be submitted for approval:
Review and Document Patient's Medication History
Will be submitted
Review Laboratory and Diagnostic Test Results
Analyze the results of laboratory tests, radiological scans, and other diagnostic procedures relevant to the patient's preoperative assessment. Review parameters such as bloodwork, imaging studies, electrocardiograms (ECGs), and pulmonary function tests. Identify any abnormalities or deviations from the normal range. Document the findings accurately and consult with the surgical team and anesthesiologist if further evaluation or interventions are necessary.
Assess Patient's Emotional Status and Anxiety Levels
Evaluate the patient's emotional well-being and anxiety levels regarding the upcoming surgery. Engage in a supportive and empathetic conversation to address any fears, concerns, or misconceptions. Assess the patient's understanding of the procedure, anesthesia, and expected outcomes. Provide reassurance, counseling, and educational resources as needed. Document the emotional assessment findings and communicate relevant information to the surgical team and anesthesiologist.
1
Calm
2
Anxious
3
Fearful
4
Depressed
5
Confused
Evaluate Surgical Risk Factors
Identify and evaluate specific risk factors associated with the planned surgical procedure and the patient's individual health status. Consider factors such as age, comorbidities, smoking history, obesity, and previous adverse reactions to anesthesia or surgery. Assess the patient's overall fitness for surgery and determine the level of risk involved. Document the risk assessment findings accurately and collaborate with the surgical team and anesthesiologist to develop an appropriate care plan.
1
18-30
2
31-45
3
46-60
4
61-75
5
Above 75
1
Hypertension
2
Diabetes
3
Heart Disease
4
Pulmonary Disease
5
Renal Disease
Perform Anesthesia Consultation
Engage in a detailed discussion with the patient about anesthesia options, risks, benefits, and alternatives. Assess the patient's anesthesia-related concerns, expectations, and preferences. Evaluate the patient's eligibility for different types of anesthesia based on their health status, surgical procedure, and risk factors. Document the anesthesia consultation findings accurately and collaborate with the anesthesiologist to develop an appropriate anesthesia plan.
1
General Anesthesia
2
Local Anesthesia
3
Regional Anesthesia
4
Monitored Anesthesia Care
5
No Preference
Approval: Anesthesia Consultation
Will be submitted for approval:
Perform Anesthesia Consultation
Will be submitted
Consent Form Review
Ensure the patient understands the consent form for the planned surgery. Review the content of the consent form together with the patient, explaining the nature of the procedure, potential risks, anticipated benefits, and alternative treatments. Address any questions or concerns raised by the patient and ensure their complete comprehension before proceeding. Document the consent form review process and the patient's consent status.
1
Consent Signed
2
Consent Pending
3
Consent Declined
Approval: Consent Form
Will be submitted for approval:
Consent Form Review
Will be submitted
Discuss Preoperative Instructions with Patient
Provide clear and concise preoperative instructions to the patient to ensure their cooperation and preparation for the upcoming surgery. Cover topics such as fasting guidelines, medication administration, hygiene practices, arrival time, required attire, and transportation arrangements. Address any specific instructions related to the surgical procedure or anesthesia. Emphasize the importance of adhering to the provided instructions for a smooth and safe surgical experience.
Update Patient's Medical Record with Preoperative Assessment Information
Record all relevant preoperative assessment information in the patient's medical record. Ensure accurate documentation of findings, recommendations, assessments, and discussions. Follow proper medical record keeping guidelines and protocols to maintain confidentiality, integrity, and accessibility of the information. This step is crucial for continuity of care, future reference, and communication among healthcare providers involved in the patient's treatment.
Prepare Preoperative Care Plan
Develop a detailed preoperative care plan based on the patient's individual needs, surgical requirements, and assessment findings. Include instructions for preoperative medications, laboratory tests, diagnostic procedures, and special preparations. Coordinate with the surgical team, anesthesiologist, and other healthcare professionals involved in the patient's care. Document the care plan accurately and ensure its availability to the surgical team and relevant staff members.
Communicate Care Plan to Surgical Team
Effectively communicate the preoperative care plan to the surgical team to ensure a coordinated and streamlined surgical process. Share essential details of the care plan, including medication instructions, special considerations, anesthesia preferences, and risk factors. Address any specific concerns or requirements raised by the surgical team members and collaborate for a comprehensive patient-centered approach.
Verify that Patient Understands Procedure and Post-Operative Care
Confirm the patient's understanding of the surgical procedure and post-operative care instructions. Engage in a comprehensive conversation to assess their knowledge, expectations, and ability to comply with the recommended care plan. Address any misconceptions, clarify doubts, and reinforce important information. Document the verification process and consult the surgical team and anesthesiologist for further guidance if required.
1
Fully Understands
2
Partially Understands
3
Needs Further Explanation
Ask Patient to Sign Consent Form
Request the patient's signature on the consent form to acknowledge their voluntary agreement to undergo the planned surgery. Provide the patient with a clear understanding of the consent form's content, risks, benefits, and alternatives. Offer sufficient time for the patient to review the form and address any last-minute concerns or questions. Ensure the consent form is signed and dated properly, adhering to legal and ethical requirements.
