ࡱ>  [bjbjaa P5``004h05t("""%% %5555555,+9;D5-%%"%%%D5'00""hq5'''%08""5'%5''rN1hr2C#X&155051zs<'s<r2'r2%%%D5D5'%%%5s<%%%%%%%%%` :     Scheduling Worksheet Physicians Office Information Physician Name: _______________________________ Surgeon/Medical Student Assist: ____________________________ Referring Physician: ___________________________ Contact Person:_____________________Phone_________________ Surgery Date: _________________________________ Length of Procedure: __________________Start Time: __________ CPT Codes: ___________________________________ ICD-10 Codes: ____________________________________________ Planned Procedures: ________________________________________________________________________________________ Patients BMI:_____________ If BMI is over 50, please refer case to the hospital. Patient Has: ( Pacemaker ( Defibrillator If so please include a copy of the patients Cardiac Rhythm Management Devices (CRMD) card when scheduling. For patient safety we need the make and model so we can notify the representative to be here during the procedure. Patient Information Patient Speaks: Spanish % English % Both % Patient s Name:___________________________________________ Sex: M F DOB: ____________ Under 18 Y N Last 4 Digit of SS#:________________________________________ Responsible Party Name (if pt < 18):______________________________________ Relationship:___________________________ Email:_______________________ Home Phone #:_________________________ Work Phone #:__________________________ Address: _____________________________Apt/Unit #________City:______________________State:__________Zip__________ Does Patient live in a Skilled Nursing Facility: Y N If YES Name of Facility:______________________________________ SNF Address: ______________________________________________________________________________________________ Insurance Information Insurance Carrier: _________________________________________Cardholder Name:__________________________________ Card Holders DOB: _______________________________________Medicaid ID #: __________________________________ Pre-Authorization #:________________________________ FYI Cignas new policy updates now require pre authorizations on almost all procedures and implants (call if you would like a copy of the pre auth list). BC/BS has also updated their Medical Necessity Requirements. Work Comp Carrier:____________________________________ Claim Adjuster Name: __________________________________ Date of Injury________________ WC Case #: _______________________________ WC Auth #: _________________________ Special Requests Type of Anesthesia (circle one): General Local MAC Regional: Spinal Block Axillary Block Bier Block IV Block Anesthesia Special Requests: ___________________________________________________________________________________ Overnight Stay: Y N * Must be discharge in <24 hours. Pathology Required (circle one): Routine to PVH Stat to PVH Special Equipment Needed: ___________________________________________________________________________________ Implants Requested: _________________________________________________________________________________________ Additional notes pertaining to patient or the case: _________________________________________________________________ Important HSC Information At the time of scheduling please fax a copy of the scheduling worksheet and insurance card. Required information is in BOLD and ITALICS. If the information is not completed, please expect a phone call from one of our schedulers. Additional information required 72 hours prior to the case; patient consent, pre/post-op orders and the H&P. Please fax to (970) 297-6330. Pre-Op Admit Orders Patient Name: Patient Weight: Surgery Date: Physician: DX or Procedure: Allergies( NKDA Laboratory( CBC ( PT/INR ( BMP ( Urine HCG (Other:Cardiovascular/X-Ray ( EKG: _____To be read by Cardiologist _____ Used as Baseline ( CXR ( Other:________________________________Pre-Op Prep ( Hair Removal:____________________ ( Scrub: _____Betadine _____Hibiclens _____Prevail _____ Other:_____________DVT Prophylaxis (Venous Pressure Pumps ( Low-Risk Patient/Procedure NO DVT Prophylaxis ( Ted Hose: Thigh High or Knee HighProphylactic Antibiotic OrdersSevere Penicillin allergy or cephalosporin allergy (hives, shortness of breath, laryngeal edema, and/or anaphylaxis) ( Yes or ( No NOTE: Adult Indications for using Vancomycin Physician/APN/PA/Pharmacist documentation of MRSA; High risk due to acute hospitalization within the last year; High risk due to stay in long-term care facility within last year (prior to this admission); Physician/APN/PA/Pharmacist documentation of increased MRSA rate associated with the procedure; Chronic wound care or dialysis; Other physician/APN/PA/Pharmacist documented reason SurgeryMedicationAdminister within:Redose during procedureHip/Knee Arthroplasty Adult:(CefazolinOrthopedic/Podiatry ( For patients < 80 kg, 1 gm IV60 mins prior to incision4 hrs  ( For patients > 80 kg, 2gm IV60 mins prior to incision4 hrsIf severe penicillin or cephalosporin allergy administer:( Clindamycin 600mg IV60 mins prior to incision4 hrs( Vancomycin 1gm IV (admin over 1 hr)2 hours prior to incision8 hrs Pediatric:Ancef ________ mg/kg up to ____________ mg Other: 60 mins prior to incisionPer PhysicianGenitourinary Adult: Transrectal Prostate( Levofloxacin 500mg IV (admin over 1 hr)2 hours prior to incisionSingle-dose only( Clindamycin 600mg IV AND Gentamicin 100mg IV60 mins prior to incision4 hrs( Metronidazole 500 mg IV AND Gentamicin 100mg IV60 mins prior to incision6 hrs Pediatric:Ancef ________ mg/kg up to ____________ mg Other: 60 mins prior to incisionPer PhysicianHead and Neck Adult:( Cefazolin ( For patients < 80 kg, 1 gm IV60 mins prior to incision4 hrs  ( For patients > 80 kg, 2gm IV60 mins prior to incision4 hrsIf severe penicillin or cephalosporin allergy administer:( Clindamycin 600mg IV60 mins prior to incision4 hrs Pediatric:Ancef ________ mg/kg up to ____________ mg Other: 60 mins prior to incisionPer PhysicianOther Surgeries Adult:( Cefazolin ( For patients < 80 kg, 1 gm IV60 mins prior to incision4 hrs ( For patients > 80 kg, 2gm IV60 mins prior to incision4 hrs( Cefoxitin 2gm IV60 mins prior to incision2 hrs *****If allergic to PCN, give:( Clindamycin 600mg IV60 mins prior to incision4 hrs( Vancomycin 1gm IV (admin over 1 hr)2 hours prior to incision8 hrs( Metronidazole 500mg IV60 mins prior to incision6 hrs( Levofloxacin 500mg IV (admin over 1 hr)2 hours prior to incisionSingle-dose only Pediatric:Ancef ________ mg/kg up to ____________ mg Other: 60 mins prior to incisionPer PhysicianAdditional Day of Surgery Orders  Physician Signature Date Time CONSENT FOR SURGERY SURGERY OR OTHER PROCEDURE: I, permit Dr. / Assistant (as needed) and any other doctors or assistants needed to assist in performing the surgery/procedure my doctor has recommended. An assistant may perform one or all of the following tasks under the supervision of my primary surgeon: opening and closing, harvesting grafts, dissecting tissue, removing tissue, implanting devices, and altering tissues. The surgery procedure my doctor has recommended is: Right / Left THIS SURGERY OR PROCEDURE HAS BEEN RECOMMENDED BECAUSE: MY OTHER TREATMENT OPTIONS INCLUDE: I acknowledge that I have read and understand the following risks related to anesthesia. By signing this consent, I allow the use of any anesthetics, sedatives or other medications as directed by my surgeon, anesthesiologist, or certified nurse anesthetist working under the direction of an anesthesiologist that may be necessary. I understand that the administration of anesthesia, including sedation, carries with it certain risks above and beyond those relating to the procedure itself. These risks include, but are not limited to: respiratory (breathing) problems; blood pressure problems; irregular heart beat; irritability; nausea and vomiting; prolonged drowsiness; damage to teeth and/or dental work; unsteadiness; failure to achieve adequate sedation and/or possible awareness or memory of the procedure; allergic or unexpected and possibly severe drug reactions; nerve damage; extended hospital stay and death. I UNDERSTAND THAT: Any surgery or procedure and the use of anesthesia have some risks. These risks can be serious and in rare cases result in death. Treatment results are not guaranteed and may not cure the condition. I consent to the presence of observers in the operating room, such as students, medical residents, medical equipment representatives, or other appropriate parties approved by my physician(s). Medical students may participate in my surgical care under the direct supervision of my physician(s). I consent to the disposal of any human tissue or body part which may be removed during the surgery / procedure(s). The risks listed below are the more common risks, but are not all the possible risks associated with this operation or procedure. RISKS: The most common risks are bleeding, infection, nerve injury, blood clots, heart attack, allergic reactions and pneumonia. Other risks of this particular operation or procedure include: SURGERY PATIENTS: If during my surgery the doctor finds an unsuspected medical need, I permit him/her to provide the necessary treatment(s). My doctor has fully explained the surgical procedure in words I understand, I have read and fully understand this consent form, and all of my questions have been answered. Do not sign unless you have read and thoroughly understand this form. Patient/Responsible Party Date Time Witness Date Time Physician Date Time CONSENT FOR SURGERY OR OTHER PROCEDURE Patient Identification TRANSFUSION CONSENT BLOOD TRANSFUSIONS I also understand that I may need to receive blood or blood products while I am in the facility. I understand there are several options I may consider in receiving blood. I may have: Blood donated by myself for my own use (self-donated blood). Blood donated by friend or family for my use (directed donors). Blood currently available to the hospital from other donors (banked blood). Other sources are: I UNDERSTAND SOME OF THE COMMON RISKS OF RECEIVING BLOOD OR BLOOD PRODUCTS ARE: getting an infectious disease (such as hepatitis or AIDS) bad reactions such as: fever, hives, high blood pressure, shortness of breath, and heart or kidney problems. I UNDERSTAND THAT: Results of blood transfusions are not always successful and that guarantees cannot be made that the transfusion will help me. Losing large amounts of blood may result in death, if blood is not replaced. All donors are carefully screened, and all blood is tested thoroughly and properly. Blood donated directly for my use by friends or family has NOT been shown to be safer than banked blood. If blood I donated to be given back to myself tests positive for AIDS or hepatitis, it will be discarded to protect the health care workers from the hospital. If there is not enough donated blood for my use (either self or directed donations), blood from the Blood Bank will be used. This consent to blood transfusion(s) is effective throughout this admission. My doctor has fully explained the possibility of blood transfusion in words I understand. I have read and fully understand this consent form, and all of my questions have been answered. Do not sign unless you have read and thoroughly understand this form. Patient/ Responsible Party Date Time Witness Date Time Physician Date Time I refuse to receive blood or blood products for any reason. My doctor has explained the likely complications that may occur if I need blood and do not receive it. I will accept all risks associated with my refusal to receive blood and will release my doctor and Harmony Surgery Center, LLC, from any responsibility for any bad results, including my death, which may occur because I refused to accept blood or a blood product. (Please put your initials here if refusing blood or blood products.) Patient Identification CONSENT FOR SURGERY OR OTHER PROCEDURE  Short Form History and Physical INDICATIONS/SYMPTOMS:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ PAST MEDICAL HISTORY, FAMILY & SOCIAL HISTORY:__________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________ EXISTING COMORBID CONDITIONS:____________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________ DRUG ALLERGIES:___________________________________________________________________________________________ ___________________________________________________________________________________________________________ MEDICATIONS, DOSAGE & FREQUENCY:________________________________________________________________________ ___________________________________________________________________________________________________________ PHYSICAL EXAMINATION: BP:________________ PULSE:________________ NORMAL COMMENTS ( MENTAL STATUS: ________________________________________________________________________________________ ( LUNGS:__________________________________________________________________________________________________ ( HEART:__________________________________________________________________________________________________ ( EXAM SPECIFIC TO PROPOSED PROCEDURE:_________________________________________________________________ ___________________________________________________________________________________________________________ ( PATIENTS GENERAL CONDITION:___________________________________________________________________________ ___________________________________________________________________________________________________________ ASSESSMENT AND PLAN:____________________________________________________________________________________ ___________________________________________________________________________________________________________ Patient Identification _____________________________________________ PHYSICIAN SIGNATURE DATE White Medical Records; Yellow Physicians Office  FILENAME \p \* MERGEFORMAT S:\HSC\HSC-MED_REC-FORMS\2017 HSC Clinical Forms\HSC Forms\Short-Form-H&P.docx Rev 1/17 HARMONY SURGERY CENTER, LLC Patient Admission Assessment Form **Patient: Please begin here and complete the information below List your allergies to Medicines, Latex (rubber), Food, Tape, Other: List your previous surgeries/hospitalizations: Prior to your discharge, do you grant our staff permission to go over procedural information, medications and discharge instructions with your ride home? ( Yes ( NoName and phone number of ride home (note - patient is advised to have a responsible adult with them for 24 hours after procedure):  Who is your Primary Care Physician: Health History:YesNoHeight: Weight: Seizure/stroke or other neurological problem?Problems with your heart?Chest pressure, chest pain?Shortness of breath with exertion or exercise?Pacemaker or defibrillator?Cardiac stent/blood vessel stent or cardiac bypass?High blood pressure?Blood thinner medication? Clotting problems?Take aspirin or aspirin-like meds (i.e., Motrin, Aleve, etc.)?Blood disorder?Autoimmune disorder?Lung problems or problems breathing?Do you currently smoke?Have you ever smoked? When did you quit?Supplemental oxygen?Sleep apnea?Kidney problems?Gastrointestinal or liver problems?Diarrhea and/or abdominal cramping? For how long?Thyroid, Parathyroid, or adrenal gland problems?Cancer treated with chemotherapy or radiation? Currently have a contagious or infectious condition?Illness, infection or fever in the past 2 weeks?Diabetes and/or high blood sugar?Taken steroids (i.e. Prednisone) in the last year?Suffer from anxiety, nervousness, or panic attacks?Mental health concerns?Used recreational drug(s) within the last 3 days?Smoked or consumed marijuana in the past 3 days?Drink alcohol? Frequency?Dentures or problems with your teeth?Eye or vision problems? Health History Continued:YesNoHearing problems?Physical restrictions?Frequent heartburn?Object to blood products under any circumstances?Problems with anesthesia (self or blood-relative)?Any concerns about anesthesia?Is there any possibility you could be pregnant?Currently breastfeeding?Date of your last menstrual period?Do you have an advance directive: ( CPR Directive ( Living Will ( Power of Attorney ( OtherDo you have someone who can help you at home if needed?Do you have any anticipated discharge needs?BelongingsPlease list any belongings you have with you upon admission to HSC ( Wallet ( Purse ( Rings ( Glasses (Other: ( Phone ( Piercings ( Dentures ( Hearing Aid(s) Note: HSC cannot be responsible for belongings. Please give valuables to your ride home. Education AssessmentDo you or your responsible party need information on the following? ( None ( Rehab Techniques ( Medications ( Treatment/Procedures ( Current Illness ( Access to follow-up care ( Diet/Nutrition ( Personal Hygiene/Grooming/Oral Care ( Home Care ( Community Resources ( Equipment ( OtherPreferred Learning Method: ( Listening ( Demonstrations ( Videos ( Reading ( Hands-On ( NoneBarriers: Check all that apply ( None ( Language ( Physical ( Cognitive ( Culture ( Financial ( Hearing ( Vision ( Desire/Motivation ( Read/Write ( Emotional ( Religion ( Other:Pain EvaluationPain: ( Yes ( No If yes, please complete the following: Pain Level (1-10) Location: Onset/Duration: Description: ( Dull ( Sharp ( Burning ( Aching Current pain treatment: ( Meds ( Ice ( Elevation ( Heat ( Massage ( Other:  Signature of patient or person completing form: X  Medication Reconciliation Form **Please list all medications on this form. We are NOT able to accept a copy of your medications** Patient: Please list all medications taken on a regular basis (including over the counter and herbal preparations). Medication NameDoseRouteFrequencyLast TakenRN to complete: Continue after discharge OR refer to prescribing physician: CONTINUE REFER to MD1.((2.((3.((4.((5.((6.((7.((8.((9.((10.((11.((12.((13.((14.(( New Prescriptions Prescribed at HSCDoseRouteFrequencyLast TakenUse1.2.3.4.I will be provided with a copy of this list upon discharge. Please note, all routine medications marked REFER to MD should be clarified with the prescribing physician before continuing. Medication Safety: To safely manage routine and new medications, it is important to give a copy of your Medication Reconciliation Form to your primary care physician. It is also important to update the information when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added. Patient/Responsible Party Signature: Date:  RN Signature: Date:      FILENAME \p \* MERGEFORMAT S:\HSC\HSC-MED_REC-FORMS\2017 HSC Clinical Forms\HSC Forms\Patient Admission and Procedure Documentation-Pg 1.docx Rev 1/17  FILENAME \p S:\HSC\HSC-STAFF\HSC-Business-Office\HSC-Forms-Logs\2013-HSC-Forms-Logs\HSC-Scheduling-Worksheet.doc Rev 10.13 Patient Identification   !"@CDRUbdorstֽ~sh`X`sJ>h=Jh5856CJaJh=Jh58556CJaJhgLCJaJhCJaJhhQqCJaJhh8xCJaJhh585CJaJh=Jh8x56CJaJ h56 hsf56hh56h_Yht56CJaJh_Yh556CJaJhA-56CJaJhY:-56CJaJ jh-_YhA-UmHnHuh5h556CJaJ"D " &$d%d&d'dNOPQgdfU&$d%d&d'dNOPQgd8x&$d%d&d'dNOPQgdgdY:-    , / > J M O P Q d g j t x ӖӖӈzqӖǖhh6CJaJhY0j6CJaJhNhY0j56CJaJh=Jh8x56CJaJh=JhQq6CJaJh=Jh58556CJaJhsf6CJaJhsfhsf56CJaJh=Jh6CJaJh=Jh8x6CJaJhsf56CJaJh=Jh5856CJaJhgL6CJaJ(    ! 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