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New H&P Process For All SFGH Elective Surgeries Implemented

New H&P Process For All SFGH Elective Surgeries Implemented

Questions about the below process? Please contact Marika Russell, Medical Director for Surgical Specialties, MDRussell@ohns.ucsf.edu.

As many of you know, we have been working on streamlining the surgical H&P process.  By combining documentation from Anesthesia and the surgical service, we are able to eliminate the H&P form and still meet regulatory requirements. Effective immediately, the Surgical H&P form will no longer be required to book a case or bring a patient to the operating room.  Instead, documentation will be culled from the Anesthesia H&P and the surgeon’s clinic note. A revised interval H&P form will be completed by the surgical team on the morning of surgery to account for any clinic note that was written 30 days before surgery.

The breakdown of documentation will follow existing clinical practice and is documented here:

SFGH H&P Components Anesthesia H&P Surgical Service Clinic Note /Interval H&P
Chief complaint/reason for surgery

X

X

History of present illness

X

Past medical history/surgical history

X

Current medications

X

Allergies/adverse drug reactions

X

Review of Systems

X

Physical Examination

X

X

Diagnostics (if relevant)

X

X

Assessment

X

X

Plan

X

X

The Anesthesia Preop Clinic has been instrumental in streamlining this process. Effective immediately, all patients scheduled for elective surgery should be seen in Preop clinic. When surgery is scheduled/booked, please enter an eReferral to have your patient scheduled in Pre-op clinic. The eReferral will prompt an automatic email to the primary care provider for your patient, indicating the date of surgery and the procedure scheduled. A visit with the primary care provider will only be necessary if Pre-op clinic determines that further work-up or treatment is required prior to providing anesthetic clearance. In an effort to provide patient-centered care, drop-in visits to Anesthesia Preop Clinic are welcomed; please call ahead to 206-5693 to ensure availability.

Because the H&P form does not need to be completed, patients can be scheduled for surgery well in advance of their surgical date. Please complete the booking form and consent form during the visit in which surgery is scheduled. A return visit will not be required to complete paperwork, as neither the consent form nor the booking form expire (unless the nature of the surgery changes).

Pediatric patients do not need to be seen for clearance by their primary pediatrician. Pediatric patients will be seen in Preop Clinic following the same pathway as adult patients.

Please note that labs, CXR, EKG do not need to be ordered by the surgical service; these diagnostic studies will be ordered by the Anesthesia Preop Clinic as indicated. Many services have provided specific clinical guidelines to the Preop Clinic regarding perioperative management of their patients.  We encourage you to work with Dr. Oliver Radke, Medical Director of Anesthesia Preop Clinic, to communicate your expectations for perioperative management of your patients (meds, labs, etc).

The nurses of the Anesthesia Preop Clinic educate the patients about how to prepare for surgery. Copies of the preop teaching form are available on the Preop Clinic website (www.sfghpreop.org). If you have any special instructions you would like your patients to receive (e.g. bowel prep, skin cleaning), please let Dr. Radke know.

Finally, while this transition is underway, there will be patients who are currently scheduled for pre-op visits. Those visits should still be completed (without the H&P form) to ensure there are no gaps in care.  Ultimately, elimination of these pre-op visits should allow for greater clinical productivity. Our expectation is that we will see clinic wait times decrease as a result of this process.

2017-11-16T12:16:48+00:00 August 14th, 2013|