Nursing staff admitting the patient will review the following.
A review of patient notes includes checking the following documents:
- Recommendation for admission (RFA) form
- Patient health questionnaire (PHQ)
- Transfer of care (discharge) from hospital planning questionnaire (TCPQ)
- Consent
A pre-admission clinic assessment review may include:
- checking current medications
- confirming any preoperative blood tests or imaging
- reviewing any specialist or hospital discharge letters
A patient may have specific medication instructions or preoperative medication administration requirements.
Local and national guidelines exist to guide clinicians regarding specific medication management. For instance, the Australian Diabetes Society (ADS) and the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (ANZCA) developed the Perioperative Diabetes and Hyperglycaemia Guidelines (Adults) to manage patients with diabetes and hyperglycemia throughout the perioperative journey.
A review of pathology requirements may include confirming any preoperative tests or any tests required on the day of surgery.
On the day of surgery, nursing staff will complete the patient’s admission by:
- confirming patient identification and verifying procedure
- recording vital signs
- confirming fasting times
- confirming allergies and alerts
- conducting a venous thromboembolism risk assessment
- conducting a Waterlow Pressure Ulcer Scale assessment (only if not completed at a pre-admission clinic)
- conducting a falls risk assessment for patients over 65 years of age with cognitive impairment or neurological disease (only if not completed at a pre-admission clinic).
Resources
ADS-ANZCA Perioperative Diabetes and Hyperglycaemia Guidelines (Adults)
A practical guideline for perioperative diabetes management for adult elective surgery.
Source: Australian Diabetes Society
Surgical safety or preoperative checklists
Use surgical safety or preoperative checklists to improve a patient’s experience and outcomes in perioperative care.1-4
Adapt and modify checklists to fit your local processes.5
Resources
Clinical Procedure Safety Policy Directive
A policy directive for clinical care and patient safety risks associated with clinical procedures.
Source: Clinical Excellence Commission
Perioperative Patient Record – Preoperative Checklist
A checklist to support clinicians in the preparation of patients for surgery.
Source: Clinical Excellence Queensland, Queensland Health
Surgical Safety Checklist (Australia and New Zealand)
A checklist of critical safety steps to be completed in operating rooms. The Royal Australasian College of Surgeons adapted their checklist from the World Health Organization Surgical Safety Checklist.
Source: Royal Australasian College of Surgeons
Venous Thromboembolism (VTE) Risk Assessment Tool
Risk assessment tool for adult inpatients.
Source: Clinical Excellence Commission
WHO Surgical Safety Checklist
A checklist that aims to decrease errors and adverse events in surgery.
Source: World Health Organization
References
- World Health Organization. WHO Surgical safety checklist. Geneva, Switzerland: WHO; 2009 [cited 27 Mar 2024].
- Abbott TEF, Ahmad T, Phull MK, et al. The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis. Br J Anaesth. Jan 2018;120(1):146-55. DOI: 10.1016/j.bja.2017.08.002
- Clinical Excellence Queensland. Perioperative patient record - preoperative checklist. Queensland, Australia: Queensland Health; 30 May 2022 [cited 27 Mar 2024].
- Murphy K, Walker K, Duff J, et al. The collaborative development of a pre-operative checklist: An e-Delphi study. ACORN. 2016;29:36-43. DOI: 10.26550/2209-1092.1002
- Royal Australasian College of Surgeons. Surgical safety checklist (Australia and New Zealand). Sydney, Australia: RACS; Oct 2009 [cited 27 Mar 2024].