Surgical Booking Reference Guide

Transcription

Surgical Booking Request
Office Reference Guide
Purpose: This reference guide is intended for Physicians & office staff. It contains information
regarding the Surgical Booking Request and the OR booking rules.
Recipient: Physicians & office staff who are responsible for booking surgical or operating room
procedures.
Contents
Page
1
2
2
Policy and Procedures
2
3
Surgical Booking Request (SBR) Form and Location
2
4
Surgery Specific Forms
3
5
Getting Started
3
6
How to fill out the SBR form
4
7
Contact List
9
8
Frequently Asked Questions (FAQ’s)
10
Appendices
Appendix A
Surgical Booking Request (SBR) form
11
Appendix B
Booking Flow Diagram
12
Appendix C
Total Hip Joint Surgery Request form- Hips
13
Appendix D
Total Joint Surgery Request Form
14
Knees/Shoulder/Elbow/Ankle
Appendix E
FMC Spine Surgery Request Form (2 sides)
15
Appendix F
Creutzfeldt Jacob Disease (CJD) Risk Assessment Tool
17
Generated: 2011-02-25
Source: CAL ORIS
Internal: Training-Manuals
Page 1 of 17
Disclaimer: This report is confidential. If received in error, notify Surg Svcs Office at 403.944.2433
The Surgical Booking Reference Guide provides information to assist in booking a surgical
patient. Electronic links to this Reference Guide can be found on:
The External Web Site at:
 http://www.calgaryhealthregion.ca/surgicalservices/surgeon_offices.html
 http://www.calgaryhealthregion.ca/surgicalservices/nhsf.html
The Internal Web Site at:
 http://iweb.calgaryhealthregion.ca/surgicalservices/data_analytics.html
Click Information for Surgeon Offices box
Policy and Procedure
The Alberta Health Services (AHS) Calgary zone has 2 policies that apply specifically to surgeon
offices submitting elective surgical bookings. Electronic links to these policies can be found on:
Internal Web Site.
1.
Policy 0-47 Schedule Elective Block Release
http://iweb.calgaryhealthregion.ca/surgicalservices/or_policies/O_47%20.pdf
2.
Policy 0-48 OR Booking Release
http://iweb.calgaryhealthregion.ca/surgicalservices/or_policies/O_48.pdf
Paper copies may be requested via the Surgical Booking Office, but will be current to the date
distributed to the office.
Surgical Booking Request Form and Location
The Surgical Booking Request Form (SBR) number 101882 (2011/02) is available in two formats,
a triplicate hard copy paper form and an electronic form. Electronic forms are filled out via the
computer and 3 copies are printed off. Triplicate hardcopy paper forms are filled out by hand
using legible printing and black ink. Triplicate hardcopy paper forms are available from Data
Management (DDM) forms provider or site location.
Electronic links to the form can be found on:
 http://iweb.calgaryhealthregion.ca/surgicalservices/data_analytics_forms.html
The External Web Site at:
Information and documents for Surgeons’ Offices can be found in both.doc and .pdf files:
 http://www.calgaryhealthregion.ca/surgicalservices/surgeon_offices.html
In the 'Document' column as link ' OR Booking Request Form - Microsoft Word'.
In the 'Document' column as link ' OR Booking Request Form - Adobe PDF'
Information and documents for Information for Non-Hospital Surgical Facilities can be found in a
.doc files:
 http://www.calgaryhealthregion.ca/surgicalservices/nhsf.html
In the 'Form column as link ' Surgical Booking Request Form '.
Surgery Specific Forms
Surgery specific forms have been created to facilitate the surgical booking process for all total
joint replacement arthroplasties, all spinal surgery procedures and all patients with CJD
precautions. Electronic links to the forms can be found on:
Source: CAL ORIS
Page 2 of 17
The External Web Site at
a. CJD Risk Assessment Tool
http://www.calgaryhealthregion.ca/surgicalservices/suites_forms/surgeon_offices/cjd_ri
sk_assessment_tool.pdf
b. Total Hip Joint Surgery Request
http://www.calgaryhealthregion.ca/surgicalservices/suites_forms/surgeon_offices/total
_hip_joint_surgery_request.pdf
c. Total Joint Surgery Request Form (Knee/Shoulder/Elbow/Ankle)
http://www.calgaryhealthregion.ca/surgicalservices/suites_forms/surgeon_offices/total
_joint_surgery_request.pdf
d. FMC Spine Surgery Request Form
http://www.calgaryhealthregion.ca/surgicalservices/suites_forms/surgeon_offices/fmc
_spine_surgery_request.pdf
 http://iweb.calgaryhealthregion.ca/surgicalservices/data_analytics_forms.html
Printed copies are available from Site Specialty Nurse Clinician.
Getting Started
All patients who have made a decision to have surgery must have their surgical booking package
submitted for inclusion on the AHS Waitlist. All submissions to the Site Admitting departments
must consist of original documents, or triplicate form copies, faxed copies are not accepted by
Admitting. There are two options for waitlist submission:
1. Date for Surgery Confirmed
The Surgical Office completes the Surgical Booking Package and submits it to the Site
Admitting department. The Surgical Booking Package consists of original copies of the
following:
a. Surgical Booking Form:
 2 copies of printed electronic form
OR
 White and yellow pages of hardcopy triplicate formb. Consent - complete and signed
c. History and Physical
d. Physician’s Orders for Treatment
e. Additional Surgery Specific forms as required:
 Creutzfeldt Jacob Disease (CJD) Risk Assessment Tool
 Total Hip Joint Surgery Request
 Total Joint Surgery Request form Knee/Shoulder/Elbow/Ankle
 FMC Spine Surgery Request Form
f. Pre Anesthetic form for RGH, FMC and Women’s Health patients.
The Surgical Office retains the following for reference/use:
a. Surgical Booking Form.
 1 copy of printed electronic form
OR
 Green page of hardcopy triplicate form
2.
Date For Surgery Has Not Been Decided
Source: CAL ORIS
Page 3 of 17
The Surgical Office submits the following to the Site Admitting department:
a. Surgical Booking Form:
 2 copies of printed electronic form
OR
 White and yellow pages of hardcopy triplicate form
b. Any portions of the booking package that have been completed
Once a date for surgery has been confirmed:
The Surgical Office will update their copy of the SBR with the procedure date and re-submit
the SBR and a complete Surgical Booking Package to the Site Admitting department.
The Surgical Office retains the following for reference/use:
Surgical Booking Form:
 1 copy of printed electronic form
OR
 Green page of hardcopy triplicate form
How to fill out the Surgical Booking Request Form
Please type or print legibly. All date fields are entered in YYYY/MON/DD format. All phone
numbers must include area code. RHRN, Encounter # and Date Admitting Received fields
completed by Admitting Department.
A. Site: State the physical Site (location) that the surgery will be performed at (eg: ACH,
Banff, Canmore, FMC, High River, PLC, RGH).
B. Date /submitted: Enter the Date that the surgical booking request form is submitted
C. Admitting Surgeon’s Name: Enter the Surgeon’s last name and first name.
Admitting Surgeons’s Phone: Enter Surgeon’s Office phone number.
Patient Information
D. Surname, First, Middle: Enter the patient’s Full Name.
Age: Enter patient’s age.
DOB: Enter patient’s date of birth.
Gender: Enter patient’s gender.
E. Address, City, Province, Postal Code, and Phone Numbers: Enter the patient’s
Primary Address and Phone contact information.
F. PHN#: Enter the patient’s Provincial Health Care number.
Source: CAL ORIS
Page 4 of 17
G. Parent(s): If the patient is a minor, enter the Parent(s) name(s) and Phone contact
information.
H. Legal Guardian: If the patient has a Legal Guardian assigned to them, enter the legal
guardian’s contact information and their Relationship to the patient.
I.
WCB: If the surgery is being claimed under Workman Compensation Board (WCB),
check the Yes box, and enter the WCB Claim Number.
J. Patient Available On Short Notice: If the patient is available on Short Notice (within 1-2
days) check the Yes box.
K. Patient Unavailable Dates: If the patient is Unavailable within certain dates, please
enter these dates in the From and To box
L. Admitting Physician: Enter the Admitting Physician’s name. This is usually the Surgeon
performing the Surgery. For the DI departments, this may be the radiologist.
M. Cancer: If cancer is confirmed by previous tests and if this operation is related to this
confirmed cancer diagnosis, check the Yes box. If cancer is not confirmed, check the No
box.
N. Cancer Suspected: If cancer is suspected, but has not yet been confirmed, and if this
operation is related to this possible cancer diagnosis, check the Yes box. If cancer is not
suspected, check the No box.
O. Family Physician: Enter the patient’s Family Physician’s name.
P. Provisional Diagnosis: Enter the Provisional Diagnosis as determined by the Surgeon.
Q. P-CATS Dx Cd: Enter the P- CATS (Paediatric Canadian Access Targets for Surgery)
Diagnosis Code. This is a Mandatory Field for ACH Paediatric patients only.
R. Discharge Destination: Enter the Discharge Destination, if patient is not being admitted
to hospital post surgery.
S. Signature Designation: Enter the Signature/Designation of the person completing
Patient Information section.
T. Date: Enter date section completed.
Source: CAL ORIS
Page 5 of 17
Booking Information
a. Preferred Surgery Date/ Time: Must be completed for scheduled procedures with
surgical dates that are less than 6 weeks from date submitted. Leave blank if date
unknown.
b. Decision Date for Surgery: Enter the date that the surgeon and the patient decide that
surgery is the treatment option. Note: Forms will be returned by the Admitting Department
if this field is not completed.
c. Referring MD: Enter the name of the referring MD. (family physician, General Practitioner
(GP), Specialist or alternate surgeon).
d. Referral Date to Surgeon: Enter the date that the referral was made to the surgeon by
the referring MD.
e. Admit Category All patients requiring scheduled surgical procedures are categorized
preoperatively into 2 categories: Elective or Urgent. Check the correct admit category.
 Elective Admit Category: The Elective admit category applies to those cases that
can wait 43 days or longer without any anticipated harm to the patient.
 Urgent Admit Category: The Urgent admit category is divided into sub categories
defined by the time frame, in days, within which the surgery must be performed.
•
Urgent within 3 day
•
Urgent within 7 days
•
•
•
f. P-CATS Priority Cd: Enter the P- CATS (Paediatric Canadian Access Targets for
Surgery) Priority Code. This is a Mandatory Field for ACH Paediatric patients only.
g. Admit Type: Check one applicable Admit Type. If the patient requires pre hospitalization,
enter the number of hospital days required.
h. Pre-Op Assessment Referral: If pre-operative assessment required check both the Yes
box and check Referral Type.
i.






Procedure Information:
Procedure Code 1: Enter the OR Manger Procedure mnemonic code, if known.
Procedure 1 Description: Enter the Surgeon’s description of the surgical procedure.
Procedure 1 Laterality: Check the appropriate box, if the surgery involves a paired
organ, limb or structure. If no laterality involved, leave blank.
Procedure 1 Surgeon: Enter the name of the Surgeon booking case.
Procedure 1 Skin To Skin Time: Enter the time, in minutes, required to perform the
actual surgical procedure. Skin to Skin time does not include set up, anesthesia and/or
clean up time.
Procedure 1 Insured Procedure: If not covered by AHS, check No box.
Source: CAL ORIS
Page 6 of 17


Procedure 2 Code: Enter the same information as Procedure 1 if a second procedure
is to be performed by the same surgeon.
Procedure 3 Code: Enter the same information as Procedure 1 if a third procedure is
to be performed by the same surgeon.
***If a second or additional procedure is to be performed by a different surgeon (surgeon #2), on
the same patient on the same day, surgeon #2’s office must complete a separate surgical
booking request form. Both surgeon offices must add the following comment “To be done with
Dr. X” under the Special Medical Concerns/Needs/Allergies box. Admitting and OR booking will
match these bookings together.
j.
Special O.R. Equipment/Prosthesis: Enter any Special OR equipment and Prosthesis
requests required for the surgery. Special OR equipment and Prosthesis requests must
be made at least 5 working days prior to the surgery date.
k. Special Medical Concerns/Needs/Allergies: Check the appropriate box and/or
document additional Special Medical Concerns/Needs/Alllergies in the box provided.

Autologous Blood: Check if the patient is donating their own blood prior to the
procedure

ARO: Check if the patient is confirmed to have Antibiotic Resistant Organisms.

CJD Precautions: Check if Creutzfeldt Jacob Disease precautions are required.

Latex Allergy: Check if patient has allergy to latex.

Diabetes: Check if patient is diabetic and document diabetic type, if known, in Special
Medical Concerns/Needs/Allergies field.

M.H.: Check if Malignant Hyperthermia is a medical concern.

BMI: Enter BMI value, optional field.
Note: If a second procedure is to be completed by a second Surgeon at the same time,
please note this in this box (see i above).
l.
Signature Designation: Enter the Signature/Designation of the person completing
Booking Information section.
m. Date: Enter date section completed.
Source: CAL ORIS
Page 7 of 17
O.R. Booking Office/Admitting Office Use Only
This box is to be completed only by O.R Booking Office/Admitting.
Do not enter any information in this area.
Source: CAL ORIS
Page 8 of 17
Contact List
Surgical Booking Office
Site
Phone
Fax
[email protected]
Regional
Contact
ACH
Email Addresses
403-955-2881
403-955-2899
[email protected]
403-270-0239
[email protected]
403-955-2885
FMC
403-944-1376
403-944-4055
403-944-8702
PLC
403-943-4695
403-943-4599
[email protected]
RGH
403-943-8826
403-943-8822
[email protected]
403-943-8828
Address
ACH Surgical OR Booking Office
2888 Shaganappi Trail NW, Calgary, AB T3B 6A8
FMC Surgical OR Booking Office
#903 South Tower, 1403 – 29 Street NW, Calgary T2N 2T9
PLC Surgical OR Booking Office
3500 – 26 Avenue NE, Calgary, AB T1Y 6J4
RGH Surgical OR Booking Office
7007 – 14 Street SW, Calgary, T2V 1P9
Admitting
Site
Phone
Fax (for re-submission of Waitlist SBR
when date for surgery has been
decided)
ACH
403-955-7783
403-955-7007
FMC
403-944-2203
403-270-0258
PLC
403-943-4048
403-943-4551
RGH
403-943-3516
403-943-3728
Source: CAL ORIS
Page 9 of 17
Frequently Asked Questions
What do I do if there is a change to a surgical date on a booking after it’s been submitted?
Update the original booking request with a date and new information. Submit the booking
request to the OR booking department.
Where do I call for information about completing a booking form?
Booking form information can be obtained from any admitting department. If the call is
surgery related any OR booking clerk or team leader can help you.
My booking was sent back-why?
Returned booking forms are due to incomplete information on the booking form or the
accompanying required documentation e.g. consents or history and physical. Complete
the form or the package and re-submit. Contact Site Admitting department if you have any
questions.
Date Effective: September 1, 2007
Note: Any surgical booking for the ACH Operating Room must have the mandatory fields of
PCATS and Cancer completed. If the fields are not completed the booking will be returned
to the surgeon’s office BEFORE any booking occurs.
My patient has cancer but the surgery is not related to the cancer diagnosis. What do I
mark on the cancer box?
If the surgery being booked is not directly related to the Cancer diagnosis, ie tumor
removal, mark NO. An example would be a patient who has leukemia, but needs to have a
Myringotomy and Tube Insertion for chronic ear infections.
I have everything but the consent. Should I send in the booking?
The Surgical Operating Room booking form may be submitted but the patient will be
waitlisted only. Complete packages only are accepted for surgery scheduling with a
specific date/ time.
Where can I get the SBR forms?
See page 2 of this document for web link locations (urls)
Source: CAL ORIS
Page 10 of 17
Appendix A Surgical Booking Request Form
Source: CAL ORIS
Page 11 of 17
Day Surgery/
Unit
Pre
Admission
Clinic
OR Booking
CHR Admitting
Physician Office
Appendix B OR Booking Request Flow Chart
Source: CAL ORIS
Page 12 of 17
Appendix C Total Hip Joint Surgery Request
Source: CAL ORIS
Page 13 of 17
Appendix D Total Joint Surgery Request form Knee/Shoulder/Elbow/Ankle
Source: CAL ORIS
Page 14 of 17
Appendix E FMC Spine Surgery Request Form (2 Sides)
Source: CAL ORIS
Page 15 of 17
Appendix E (continued)
Source: CAL ORIS
Page 16 of 17
Appendix F Creutzfeldt Jacob Disease (CJD) Risk Assessment Tool
Source: CAL ORIS
Page 17 of 17

Surgical Booking Reference Guide

Transcription

Similar documents

WE ARE THE PLACE TO CHILL AT THE LAKE

User Guide - Olympic Air

LET`S PARTY! - Little Monkeys

Delve Deeper into The English Surgeon

Count on St. Bernardine`s Experience and Expertise

Abdominal Sacrocolpopexy with possible removal of ovaries

Heritage Surgery Center

Holiday in Spain – La Ponderosa Holiday Home

Hiatus Hernia Surgery - University Health Network

this information