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The document consists of two main forms related to surgical procedures: a Surgical Booking Form and a Surgical Pre-Operative Test Order. The Surgical Booking Form collects patient information, referral details, surgery specifics, and necessary medical alerts. The Pre-Operative Test Order outlines required laboratory and imaging tests prior to surgery, emphasizing the need for targeted testing based on patient history and clinical indications. It also includes protocols for pre-operative testing and specific considerations for various patient categories.

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What is included in a procedure document?

It outlines the sequence of actions to be taken, specifying who should perform them and when. They ensure tasks are carried out efficiently, consistently, and safely. You can update procedures regularly and add new details or more steps.

What is included in a surgical procedure documentation?

Full description of the procedure Full written account that describes the details of the procedure including but not limited to, type and induction of anesthesia, patient positioning, set-up and use of specific tools and special equipment (e.g., stereotactic navigation, robot), approach, required implants (specific

How do I get a surgery schedule?

Contact the Surgery Coordinator, and determine what potential date you would like to schedule. You will then need to contact your Primary Care Physician to schedule your pre-op appointment within 1-3 weeks of that potential surgery date.

What is surgical procedure documentation?

Surgical documentation can simply be said as the process of recording information related to a patients surgery. However, it is not just limited to the things carried out during surgery, but also the pre-operative assessment and the post-operative course.

What counts as a surgical procedure?

Operative report. An Operative report is a report written in a patients medical record to document the details of a surgery. The operative report is dictated right after a surgical procedure and later transcribed into the patients record.

What forms do you need before surgery?

Advance Care Directive (Living will) Health Care Proxy (Power of attorney) Durable power of attorney. A synopsis of your medical history and a list of medicines you take or have taken.

What is on a surgical consent form?

You will also be asked to sign an informed consent form. It explains the procedure and its risks and benefits. This form states that you understand everything about your surgery and have had the opportunity to ask any questions and receive satisfactory answers.