Process for Surgical Services

Process for Surgical Services

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

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