2.1-2.2a SURGICAL SPECIALTY & PLANNED PROCEDURE (Please check eligibility with procedure list in SOP) 2.2b PLANNED MODE OF PROCEDURE 2.3 URGENCY OF SURGERY 2.4 ENHANCED RECOVERY PATHWAY OPEN LAPAROSCOPIC ELECTIVE EXPEDITED YES NO UNKNOWN ROBOTIC THORACOSCOPIC URGENT IMMEDIATE 2.5 PRE-OPERATIVE ASSESSMENT (Before hospital admission) NONE ELECTRONIC SELF-ASSESSMENT TELEPHONE ASSESSMENT WITH NURSE TELEPHONE ASSESSMENT WITH DOCTOR FACE TO FACE: NURSE-LED FACE TO FACE: SURGEON-LED FACE TO FACE: ANAESTHETICS-LED OTHER _______________________________________________________________________________________ 2.6 SODIUM 2.7 2.8 UREA (mmol/L) 2.9 CREATININE 2.10 ALBUMIN (g/L) (mmol/L) POTASSIUM (μmol/L) (mmol/L) 2.11 WCC (x109/L) 2.12 2.13 HEART RATE (bpm) 2.14 SYSTOLIC 2.15 GCS (3-15) HAEMOGLOBIN BP (mmHg) (g/dL) 2.16 SpO2 (%) 2.17 ECG 2.18 CARDIAC FAILURE – WHICH BEST DESCRIBES THE CARDIAC HISTORY/FINDINGS No abnormalities No failure AF rate 60-90 Diuretic, digoxin, antianginal or antihypertensive therapy AF rate >90/any other abnormal rhythm/paced rhythm/ >5VE/min/ Peripheral oedema, warfarin therapy or borderline Q, ST or T wave abnormalities cardiomegaly Not done Raised jugular venous pressure or cardiomegaly
2.1-2.2a SURGICAL SPECIALTY & PLANNED PROCEDURE (Please check eligibility with procedure list in SOP) 2.2b PLANNED MODE OF PROCEDURE OPEN LAPAROSCOPIC ROBOTIC THORACOSCOPIC 2.3 URGENCY OF SURGERY ELECTIVE EXPEDITED URGENT IMMEDIATE 2.4 ENHANCED RECOVERY PATHWAY YES NO UNKNOWN 2.5 PRE-OPERATIVE ASSESSMENT (Before hospital admission) NONE ELECTRONIC SELF-ASSESSMENT TELEPHONE ASSESSMENT WITH NURSE TELEPHONE ASSESSMENT WITH DOCTOR FACE TO FACE: NURSE-LED FACE TO FACE: SURGEON-LED FACE TO FACE: ANAESTHETICS-LED OTHER _______________________________________________________________________________________ 2.6 SODIUM (mmol/L) 2.7 POTASSIUM (mmol/L) 2.8 UREA (mmol/L) 2.9 CREATININE (μmol/L) 2.10 ALBUMIN (g/L) 2.11 WCC (x109/L) 2.12 HAEMOGLOBIN (g/dL) 2.13 HEART RATE (bpm) 2.14 SYSTOLIC BP (mmHg) 2.15 GCS (3-15) 2.16 SpO2 (%) 2.17 ECG No abnormalities AF rate 60-90 AF rate >90/any other abnormal rhythm/paced rhythm/ >5VE/min/ Q, ST or T wave abnormalities Not done 2.18 CARDIAC FAILURE – WHICH BEST DESCRIBES THE CARDIAC HISTORY/FINDINGS No failure Diuretic, digoxin, antianginal or antihypertensive therapy Peripheral oedema, warfarin therapy or borderline cardiomegaly Raised jugular venous pressure or cardiomegaly
PQIP%20CRF%20v0.11%202017-Nov-07.docx