Support.providencehospital.org

r*OP5028*rPROVIDENCE HOSPITAL6801 Airport Boulevard, Mobile AL 36608,251/633−1000OP5028Universal Protocol for Invasive Procedures
Location (Surgery/procedure area/unit):
Procedure:
Pre−operative Verification
Time Out Immediately Prior to Procedure
(Physician must be present)
Correct Patient
Correct Patient
Correct Procedure
Correct Procedure
Correct Site:
Correct Side:
Correct Site:
Correct Side:
❏ Right
❏ Right
Site Marked by Physician
Correct Position
Medical Records and Imaging
Prophylactic antibiotic received within
Available and Verified
one hour prior to surgical incision for
the procedures listed below.*
Informed Consents
History and Physical
Participants:
Time: _________
Anesthesia Evaluation ❏ Yes
Physician:
PA/SA: ❏ NA
X−rays
Anesthesia: ❏ NA
Required Equipment and Supplies Are Verified
Nurse/Tech:
Nurse/Tech:
Correct implant or special equipment available ❒ Yes
Nurse/Tech:
Nurse/Tech:
Initials/Signature
Initials/Signature
Initials/Signature
Initials/Signature
*Antibiotics are mandatory for the following procedures:
Head and neck procedures (incisions through oral or pharyngeal mycosa)
Orthopedic with Implants
Elective Craniotomy
Hysterectomy: Vaginal, Abdominal, or Radical
Spine with implants
Hernia with mesh
Cardio−thoracic
High Risk Genitourinary (ASA > 3)
Abdomincal (Gastroduodenal, Biliary)
Appendectomy (Uncomplicated)
Vascular
Colorectal
Use two methods of patient identification.
Developed 3/02
Place this form in the Consent Section of the chart.
Rev 4/02 Rev 8/02 Rev 10/02 Rev 1/05
N−Rev 3/10 NSG00003
PROVIDENCE HOSPITAL
Providence Outpatient Surgery Center
Dr. Walsh Pain Management Instructions
1. Contact your referring physician within two weeks for an appointment or follow−up phone call. DR. WALSH DOES NOT SCHEDULE ADDITIONAL INJECTIONS. Your referring physician will make that decision.
• You may drink whatever you wish.
• If possible, most patients are advised to take at least one day of rest. Get in any position that is comfortable: bed, easy chair, couch, etc.
• Physicial Therapy should be discussed with your referring physician.
• You may return to work unless your referring physician recommends otherwise.
• You may continue to take any medications you normally take. Don’t suffer. Please take prescribed pain medication when needed, not to exceed amount ordered.
• Dr. Walsh can give you a prescription for pain medication when he sees you; any additional pain medication prescriptions should be obtained from your referring physician.
• If you develop a headache that gets worse when you stand or sit and goes away when you lie down, you should call • Fifty percent of patients having a block may note pain relief in 1 to 2 days, the others 1 to 6 days.
• Cervical epidural: For 4 hours following injection − 1. Do not drive2. Do not use sharp objects.
3. Do not touch hot objects.
Metro Anesthesia (Dr. Walsh) 251−342−00041340 Sledge DriveMobile, AL 36606 I have received and understand the above instructions.
r*OP5015*rPatient Signature Date Nurse Signature Date PROVIDENCE HOSPITAL
Metro Anesthesia and Pain Services, P.C.
************************************************************************ 1340 Sledge Drive Mobile, Alabama 36606 (251) 342−0004 Diplomate, American Board of Anesthesiology With Certificate of Added Qualifications in Pain Management Fellow, American College of Anesthesiology Since the risks and benefits of the procedure have been explained to me, and since I, therefore, have areasonable idea of what to expect, I hereby give permission for Dr. DAVID G. WALSH to perform thefollowing procedure on me:_________________________________________________________________________________________________________________________________________________________________________ I understand that Dr. David Walsh is an independent practitioner and is not employed by ProvidenceHospital. My signature on this document indicates my acceptance of the above facts.
_______________________________ _______________________________ r*CONSENT*rCONSENT ANES0006
r*OP1179*rPROVIDENCE HOSPITAL6801 Airport Boulevard, Mobile AL 36608,251/633−1000NON−SURGICAL BLOCK/TREATMENT RECORD
Referring Physician: _____________________________ Date of last block (or N/A): ____________ OR#______________ PHYSICIAN’S RECORD
Risk and benefits of procedure explained and understood.
Indication(s) for Procedure:
Procedure Performed:
Patient Position:
Diagnosis:
Medications Used:
1ml 1.5% Xylocaine with Epinephrine ____________mg Depo−Medrol 1 ml Vitamin B12 IM ______gluteus _____deltoid Fentanyl ____________mcG Prescription Given:
Marcaine 0.25% PLain C−Arm exposure time ______________ Effect of injection (physician objective/patientsubjective): Other ______________________Pre−Block Vital SIgns: B/P _____ P _____ R _____ T _____ Wt. ____ Ht. _____ Pain Scale _____ (0−10)Allergies: ________________________________________________________________Current Medications: ______________________________________________________ Patient denies taking Coumadin, Plavix, Lovenox (current) Nurse’s Notes: Circulator_______________________________________________________________________________________________________________________________________________________________________________________________________________Post−Block Vital Signs: B/P _____ P_____ R _____ Pain Scale _____ (0−10)Discharge Time: ___________ Instructions to patient (see attachment) Driver Required: Dicharge Vital Signs: B/P _____ P ______ R _____ Nurse’s Signature Anesthesiologist’s Signature PROVIDENCE HOSPITAL
PHYSICIAN’S ORDERS
DATE HOUR
Intraoperative Orders
X−RAY:
❑ Portable ________
CULTURE:
FOLEY CATHETER: Insert with
SPECIMEN: ❑ To Lab
WARMING BLANKET: ❑ Upper Body ❑ Lower Body ❑ Other ______________
Apply forced air warming blanket to all open abdominal procedures and laparoscopic
colorectal procedures.
IMMOBILIZER: ❑ Knee
SCDs: Apply SCD’s, to all surgical patients, unless a contraindication is documented.
❑ Severe heart failure or pulmonary edema ❑ Immobilized for greater than 72 hours without DVT prophylaxis MEDICATIONS:
All meds ordered intraop by RN/Surgeon will be for sterile field or operative site irrigation.
❑ bacitracin 50,000 units in ______ mL Normal Saline irrigation for field / op site❑ kanamycin (KANTREX) 1 g in 3 mL Normal Saline irrigation for field / op site❑ neomycin and polymyxin B (NEOSPORIN G.U.) irrigant for field / op site ______ mL in Normal ❑ heparin ______ units in _______ mL of ________________________route used_____❑ papaverine 30 mg per mL in _______ mL of _____________________ route used_____❑ topical thrombin ______ units route used______❑ lidocaine topical 2% jelly or 2% uroject❑ Anesthetic Pain Pump ropivacaine (NAROPIN) 0.2% ❑ 100 mL ❑ 270mL ● Inpatients require use of separate Pain Pump orderset ❑ gelatin sponge (GELFOAM) ❑Fibrillar _________ ❑Nu Knit __________For operative site❑ Local ____________________________________ ❑ sodium bicarbonate _____ mL (for local) V.O.V. Dr.___________________________________ / ___________________________ RN Noted __________________________ / RN Time __________ / Date _____ / ______ / ______ SURGEON SIGNATURE: _____________________________ Date: ____/____/____ Time: ______
Developed: December 2005Revised: March 2010Revised: September 2010Revised: January 2012 PROVIDENCE HOSPITAL
UNIVERSAL PROTOCOL FOR SURGICAL PROCEDURES
❒ YES, see Med Reconciliation for listing ❒ NO BP __________ P __________ R__________ T__________ SpO2__________ TO BE COMPLETED BY PRE−OP RN
TO BE COMPLETED BY CIRCULATING RN
Completed prior to rolling to OR
Completed prior to rolling to OR
Pre−Op Time In: ____________ Pre−Op Time Out: ____________
Correct patient, ID band present/verified Correct patient, ID band present/verified Blood products are available (if ordered) Blood products are available (if ordered) Difficult airway identified by anesthesia Correct patient’s radiology reports in OR PRE−OP RN __________________________/_________/_____ PRE−OP RN __________________________/_________/______ CIRCULATING RN ________________________/_______/_____ CIRCULATING RN ________________________/_______/_____ PROVIDENCE HOSPITAL
TO BE COMPLETED BY CIRCULATING NURSE
TO BE COMPLETED BY CIRCULATING NURSE
CIRCULATOR: (Time−Out in the OR prior to incision (Surgeon must be present)**)
Site:_____________________________________ Post−op risks identified by anesthesia or surgeon TO BE COMPLETED BY PACU RN
Correct patient, ID band present/verified Antibiotic given within 1 hour prior to incision Order for VTE prophylaxis within 24 hours of surgery Order to d/c prophlactic antibiotic within 24 hours (48 hours for cardiac) Skin Integrity Issues _____________________ POA U/A obtained if patient leaves with foley No Reported or Visible Changes on Skin Integrity_____________ Additional site: __________________________________________ CIRCULATING RN ________________________/_______/_____ CIRCULATING RN ________________________/_______/_____ PACU RN __________________________/_________/_______ **PARTICIPANTS IN TIME−OUT PRIOR TO PROCEDURE Surgeon: __________________________________________ PACU RN __________________________/_________/________ Anesthesia:________________________________________ PA :______________________________________________ Nurse/ORT:________________________________________ Nurse/ORT:________________________________________ Nurse/ORT:________________________________________

Source: http://support.providencehospital.org/eForms/ops_nonsurg_block_pack.pdf