Admission Record IVF/Gynae

Transcription

1 Admission Record IVF/Gynae Surgeon: Operation : of Admission: Please state your full name and date of birth - correct Nurse Checklist Yes No Please tell me your full address - correct Consent form signed, dated and procedure confirmed by patient Procedure site marked (if applicable) Allergies: Identification band/ Alert band applied Anaesthetic Questionnaire completed & reviewed by RN Fasting confirmed (no food/fluid 6hrs prior to admission, if applicable) Patients for RhD injection: Injection available, patient has been given information by rooms, written consent sighted of trigger injection as stated by patient Nursing Admission Discharge / Carer Details Husband/ Wife Son/Daughter Friend In waiting room Call to pick up Name: Phone: Other Fasted from Diabetic Status.../.../... Solids: Hrs Fluids: Hrs Comments: Height: Cm Weight Kg Yes No Type 1 Type 2 NIDDM IDDM BSL... m/mol Meds Taken Mobility Ambulant With Assistance Walking aide Wheelchair Falls Alert Yes No Comments/Action Taken: Medication History Received Yes No Meds taken prior to admission recorded on NIMC table; Yes No Skin Integrity Intact and healthy Frail Cuts/Abrasions/Bruises Known wound Other: Affected Area/s: Action Taken: Dentures/Caps/Crowns (Circle) Hearing Aide N/A Right Left Removed Has patient been asked about all ALERT items Alert Details: Baseline Vital signs Recorded on chart Pre-Operative Medications Commenced N/A Call Bell Orientation Used bathroom Yes No Jewellery removed taped given to family Print Name Signature 1

2 Medication Chart 1 - IVF/Gynae Attach ADR sticker Diabetic on insulin Allergies and adverse reactions (ADR) Nil known Unknown (tick appropriate box or complete details below) Medicine (or other) Reaction / type / date Initials Affix patient identification label here and over leaf UR No Family name: Given names: Address: DOB: NOT A VALID PRESCRIPTION UNLESS IDENTIFIERS PRESENT Sex: Male Female Medication chart of Sign... Print Weight (Kg) Height (cm) VTE risk assessed: Yes Prophylaxis not required Contraindicated Signature Medicines take prior to presentation to hospital (Prescriber, over the counter, complementary) Own medicines brought in? Y N Administration aid (specify)... Medicine Dose and frequency Duration Medicine Does and frequency Duration GP: Community pharmacy: Sign: Print: : Medicines usually administered by: Nurse initiated medicines / Pre-Operative / Once off orders Dr Name (Print): Dr Sign: : Medicine (print generic name) Route Dose Frequency Given by Given by Given by Given by Please specify any other pre-operative requests / instructions for day surgery staff: Refer to surgeon/anaesthetist protocol 2

3 Affix patient identification label here and over leaf Medication Chart 2 Attach ADR sticker URN: Family name: Given names: Address: NOT A VALID PRESCRIPTION UNLESS IDENTIFIERS PRESENT See front page for details As required PRN medicines Year: 20 of birth: Sex: M F First prescriber to print patient name and check label correct: Medicine (print generic name) Route Dose Hourly frequency Max PRN dose/24 hrs PRN Indication Pharmacy Dose Route Prescriber signature Print your name Contact Sign Continue on discharge? Dispense? Duration:...days Qty:... : Medicine (print generic name) Route Dose Hourly frequency Max PRN dose/24 hrs PRN Indication Pharmacy Dose Route Prescriber signature Print your name Contact Sign Continue on discharge? Dispense? Duration:...days Qty:... : Medicine (print generic name) Route Dose Hourly frequency Max PRN dose/24 hrs PRN Indication Pharmacy Dose Route Prescriber signature Print your name Contact Sign Continue on discharge? Dispense? Duration:...days Qty:... : Medicine (print generic name) Route Dose Hourly frequency Max PRN dose/24 hrs PRN Indication Pharmacy Dose Route Prescriber signature Print your name Contact Sign Continue on discharge? Dispense? Duration:...days Qty:... : IV fluid administration No Type of fluid (including strength) Amount Additions to flask Prescribers signature Administration Start date Start time Finished time Total infused RN signature / time Medicine (print generic name) Telephone orders (to be signed within 24 hours of order) Route Dose Frequency Check initials Prescribers name Prescribers signature Record of administration N1 N2 / given by 3

4 Anaesthetic Record - IVF/Gynae Monitoring Yes No SaO2 B.P ECG ET Co2 Warming Blanket Temp Ventilation ASA Weight Height BMI Risks Yes No Aspiration Difficult Airway Blood Loss >500ml Airway Device & size Precautions Eyes Teeth Pressures Areas Padded ETCO 2 SaO2(%) BIS ETAgnt % General Regional Local Sedation Notes: Drugs and Fluids Regional & Local Anaesthesia Site Local Anaesthesia Regional Block Type Needle Volume Anaesthetist's Name & Signature Risks discussed with patient Yes No Notes: 4

5 Surgical Safety Checklist Before induction of anaesthesia Before skin incision Before patient leaves operating room SIGN IN At the Anaesthetic Bay Clinical handover performed from admission nurse to anaesthetic nurse Patient has confirmed Identity Site Procedure Consent Site marked/not applicable Anaesthesia safety check completed Pulse oximeter on patient and functioning Does patient have a: Known allergy? No Yes No Difficult airway/aspiration risk? Yes, and equipment/assistance available If prosthesis (or special equipment) is to be used in theatre, has it been checked and confirmed? N/A TIME OUT Clinical handover performed from the anaesthetic nurse to the theatre nurse Confirm all team members have introduced themselves by name and role Surgeon, anaesthetist and nurse verbally confirm Patient Site Procedure Prosthesis/special equipment: If prosthesis (or special equipment) is to be used in theatre, has it been checked and confirmed? Yes Not applicable Anticipated critical events Surgeon reviews: What are the critical or unexpected steps, operative duration, anticipated blood loss? Anaesthesia team reviews: Are there any patient-specific concerns? Nursing team reviews: Has sterility (including indicator results) been confirmed? Are there equipment issues or any concerns? Has antibiotic prophylaxis been given within the last 60 minutes? Yes Not applicable Has thromboprophylaxis been ordered Yes No SIGN OUT Nurse verbally confirms with the team: The name of the procedure has been recorded That instrument, sponge, needle and other counts are correct How the specimen is labelled (Including patient name) Whether there are any equipment problems to be addressed Surgeon, anaesthesia professional and nurse review the key concerns for recovery and management of this patient Name:... Name:... Name:... :... :... :... 5

6 Count Sheet - IVF/Gynae Surgeon: Scrub Nurse: Scout 1: Scout 2: Anaesthetist: Anaesthetic Nurse: Other: Entered OT Prep Used: Out /Safety Check Betadine (1/2 Strength) Procedure Start Betadine (Full Strength) Procedure End Chlorhexidine 0.5% Departed OT Chlorhexidine 0.1% (Blue) Surgical Safety Checklist Completed Other: Diathermy Yes No N/A Pathology Yes No N/A Bipolar Specimen No Monopolar Specimen Type Plate Removed Skin Intact Vaginal Pack Yes No Removed Site: Count Sheet 1st Final Tray: Tray: Needles: Raytec: Instrument loose: Dressing Applied: Count Correct: /N/A Surgeon Informed: /N/A Scrub Nurse signature: Scout Nurse signature: Chemical Change Indicator: 6

7 Operation Record (Procedure & Item No to be filled in by VMO) DATE: / / Medical Record Principal Diagnosis Operation Item Number Oocyte retrieval Exploration of spermatic cord Open surgical sperm retrieval Hysteroscopy Laparoscopy Other: Operation Notes Retrieval Details Post Operative Instructions Surgeon Signature: 7

8 Observation Chart 1 Modifications to calling criteria Admission Anaesthetic OT Recovery Discharge Respiratory Rate (breaths / min) O 2 Saturation (%) O 2 Flow Rate (L/Min) Blood Pressure (mmhg) Score systolic BP If systolic BP 140, write value in box Heart Rate (beats / min) If heart rate 140, write value in box Temperature (ºC) Consciousness If concerned, wake patient before scoring Pain Score None (0) Worst (10) Severe (7-10) Moderate (4-6) Mild (1-3) Nil Blood Sugar Level (mmol/l) Initials Write Write s 190 s 180 s 180 s 170 s 170 s 160 s 160 s 150 s 150 s 140 s 140 s 130 s 130 s 120 s 120 s 110 s 110 s 100 s 100 s 90 s 90 s 80 s 80 s 70 s 70 s 60 s 60 s 50 s 50 s 40 s 40 s 30 s 30 s 140 Write s 130 s 120 s 120 s 110 s 110 s 100 s 100 s 90 s 90 s 80 s 80 s 70 s 70 s 60 s 60 s 50 s 50 s 40 s 40 s 30 s 30 s Alert Alert To Voice To Voice To Pain To Pain Unresp Unresp Assess pain level at rest and withmovement. Enter R for at rest, M for movement Rapid Response Clinical Review 8

9 Observation Record 2 Additional Clinical Review Criteria Any Observation in the Yellow Zone Increasing oxygen requirement Poor peripheral circulation New, increasing or uncontrolled pain (including chest pain) Decrease in level of consciousness or new onset of confusion Action Required You must initiate appropriate clinical care Check whether there is an altered calling criteria Increase frequency of observations as indicated by the patient's condition, but at a minimum repeat within 30 minutes Inform the anaesthetist as soon as possible Check whether the observations reflect deterioration Additional Clinical Review Criteria All cardiac or respiratory arrests Airway obstruction Only responds to pain or unresponsive Any observation in the Red Zone Deterioration not reversed within one hour of Clinical Review Increasing oxygen requirement to maintain oxygen saturations greater that 90% Patient deteriorates further before, during or after Clinical Review Seizures Blood Glucose level less that 1 mmol/l Action Required Must initiate appropriate clinical care, monitor and stay with patient Inform Nurse in charge Repeat and increase frequency of observations Inform the anaesthetist and Medical officer as soon as practicable Phone ambulance if required Document in clinical record Modifications to calling criteria : : Valid For: Respiratory rate Sp0 2 Heart rate Blood Pressure Temperature Medical Officer Name Medical Officer Signature 9

10 Progress Notes 10

11 Discharge Record Discharge Clinical Handover completed by OT / Anaesthetic Staff to PACU nurse Arrival time in Recovery Rm Discharge time Diet and fluids tolerated Accompanying person contacted Procedure record complete Post - Op instructions explained to patient/carer and written instructions given Post - Op appointment given (if applicable) Post - Op script given (if applicable) Intravenous Cannula Removed Personal belongings returned Observations recorded on chart Wound inspected-dressing/shield intact Skin integrity at discharge as on admission Delayed discharge for clinical reasons. Riskman entry completed Patient/Carer Verification signed Chungs Modified Discharge Scoring System Vital Signs Ambulation Nausea/vomiting Pain Surgical bleeding 2 within 20% of pre op value Steady gait Minimal or none Minimal or none Minimal or none % of pre op value With assistance/aid Moderate Moderate Moderate 0 >40% of pre op value None, dizzy Severe Severe Severe Score Total /10 Patients scoring 9 or 10 are considered fit for discharge Discharge Nurse Signature: Print: 11

12 Patient /Carer Verification Patient/Carer Verification I have received and understand the discharge instructions including any medication instructions Yes No Signature Patient / Carer Print Name / patient Name Handover and Education given by: Signature Print Name 12