1. 0 Patient’s admission process in the hospital’s surgical service | |MET |PARTIALLY |NOT | | | |MET |MET | |1. 1 Evaluation of patient at the point of first contact to match the patient to surgical care | | a. Identifying the scope of care and treatment delivered to | | | | |patient either in the in-patient or ambulatory care setting | | | | | b. Proper evaluation process to ensure ability of the service to | | | | |deliver care and treatment | | | | | c. If the patient’s needs are not met, there is alternative process | | | | |for stabilizing the patient or for referral system | | | | |1.
2 Categorization according to the need of the service | | a. Priority given to immediate needs (emergency care) | | | | | b. Waiting lists are established and maintained | | | | | c. Pre-registration system for ambulatory patients (non-urgent | | | | |care) | | | | |1. 3 Operational policies and procedures are followed for admitting the patient | |.
a. Patient-related information taken from: | | | | |? patient; and/or immediate family | | | | |? patient’s significant others (friends, relatives, etc. ) | | | | |?referring practitioners | | | | |? records of previous related visits | | | | |*tick the box that applies | | | | | b. Informed consent taken from: | | | | |? patient (at legal age) | | | | |? if underage or incapacitated, patient’s father or from | | | | |patient’s brother (at legal age) | | | | |? in absence of paternal side, the head of surgical team in | | | | |knowledge of patient’s mother or immediate family | | | | |*tick the box that applies | | | | | c. Routine pre-operative work-ups | | | | |1.
4 Patient and family are provided with information during admission | | a. Orientation to service | | | | | b. Orientation to the physical environment of the service | | | | | c. Visitation protocols for in-patients | | | | | d. Introduction to caregivers | | | | | e. Routines and rules of the service | | | | | f. Patient and family’s right and responsibilities (right to | | | | |participate in decision-making regarding care and treatment; | | | | |its concerns; and compliance for safety-related requirements. ) | | | | Comments:
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_________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________ SURGICAL TEAM SERVICES ________________________________________ ( ) Paediatric Surgery Department ( ) Plastic Surgery Department ( ) Neurosurgery Department ( ) Transplant Surgery Department ( ) Eye Surgery Department PREPARATION FOR DISCHARGE, TRANSFER OR FOLLOW-UP: 6. 0 Process to discharge, transfer, and follow-up | |MET |PARTIALLY MET |NOT MET | |6. 1 Planning method starting from admission, in-patient care up to discharge/transfer/follow-up | | a.
Discharge from operation theatre including post-anaesthetic | | | | |recovery up to: | | | | |? in-patient surgical unit | | | | |? home | | | | |*tick the box that applies | | | | |6. 2 Provisions for support services (community-based services) and continuation of medical services after| | | | |discharge/ transfer: | | | | |? follow-up care post-surgery | | | | |? histopathology results | | | | |? needs further investigations (post-operative | | | | |complications) | | | | |? re-admission to hospital | | | | |*tick the box that applies | | | | |6. 3 Determination of patient’s readiness for discharge/ transfer/ follow-up includes: | | | | |
? tolerance of oral intake | | | | |?adequate pain control with oral analgesia | | | | |? ability to mobilize and self-care | | | | |? no evidence of complications and untreated medical | | | | |problems | | | | |*tick the box that applies | | | | |6. 4 Patient and family’s right to be informed well in advance for the provisions prior | | | | |discharge/transfer/follow-up | | | | |6. 5 Education of patient for discharge/transfer/follow-up : | | | | |? individual setting | | | | |? group setting | | | | |*tick the box that applies | | | | |6.
6 Clinical records and discharge summary include: | | | | |? list of discharge diagnoses | | | | |? invasive and non-invasive procedures performed during | | | | |admission | | | | |?summary of hospital course by problem | | | | |? discharge instructions | | | | |? discharge medication list (what is stopped, started, and | | | | |indications and ending dates) | | | | |? rehabilitation orders & follow-up appointments | | | | |? tests results still outstanding & alerts on problems needing | | | | |follow-up | | | | |? baseline cognitive status & physical function status at | | | | |transfer | | | | |? current advanced directives (code status, etc. ) | | | | |? include copies to Private Consulting Physicians, hospital | | | | |consultants & next venue care | | | | |*tick the box that applies | | | | |6. 7 Mandatory reports for specified diseases and events include: