Process for Surgical Services
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PROCESS FOR SURGICAL SERVICES
SDC:
PCS Status Board
. Lists
. Find Patient by one of the following methods
Find Patient by Outpatient Location
Day Surgery
Find Patient by Inpatient Location
PACU
Find Patient by Account
Enter Patient’s Name
Search
Click on Patient
Reg SDC account
Open Chart
. Go to the Summary panel
Enter Allergies
Enter Home Medication list
Enter Last Taken Information
. Click on Worklist
. Click on Add in the footer
. Click on Standards of Care at the top of the screen . Choose PAT/Amb Day Surgery set
Save
. On the Worklist check off the following assessments:
Height and Weight Assessment
Past Medical History
Patient Rights for Care Decisions
Vital Signs
Columbia Suicide Risk Rating Scale
Ambulatory/Day Surgery Adm Information assessment
Pre-Surgical Documentation Reviewed
IV/Invasive Line assessment to document the IV insertion
I&O Intake and Output assessment
PACU:
From PCS Status Board:
PCS Status Board
. Lists
. Find Patient by one of the following methods
Find Patient by Outpatient Location
Day Surgery
Find Patient by Inpatient Location
PACU Find Patient by Account
Enter Patient’s Name
Search
Click on Patient
SDC account or Inpatient account if patient was already an inpatient before going to surgery
Open patient chart
. Click on Worklist and document on:
PACU Record
IV /Invasive Line assessment
I&O Intake and Output assessment
Any other assessment needed for patient
If a patient comes to the PACU “holding area” from the ED or from the inpatient units: . Document the following assessment: PACU Holding Area-Inpt/ED Preop Note: for holding patients pre-op
For Outpatients going home from either PACU or SDC:
Document the following assessment:
. Phase II/Outpt Post Procedure Recovery assessment