Step 1 of 3
Procedure / Surgical Services Posting Sheet for Web Portal
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Location
*
Please select
Riverside Regional Medical Center
Riverside Shore Memorial
Doctor's Surgery Center
Riverside Tappahannock Hospital
Riverside Walter Reed Hospital
Hampton Surgery Center
Peninsula Surgery Center
Riverside Doctor's Hospital Williamsburg
Please select
Inpatient
Outpatient
Same Day Admit
Inpatient Only
Please select (2)
Inpatient
Outpatient
Same Day Admit
Inpatient Only
Surgery Date
*
PATIENT INFORMATION
First Name
*
Last Name
*
Gender
*
Male
Female
Address
*
City/State/Zip
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Phone
*
(home)
(cell)
(work)
Date of Birth
*
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Age
*
SSN #
*
(last four digits)
Height / Weight
*
(inches)
(pounds)
BMI
NEXT OF KIN/EMERGENCY CONTACT
Contact Name
Relationship
Phone
(home)
(cell)
(work)
WORKMAN'S COMP
Yes
No
Patient's Employer
(phone)
Contact Name
Phone
Date of Injury
Claim Number
INSURANCE INFORMATION
Is patient same as subscriber?
Yes
No
Covered by insurance?
*
Yes
No
Insurance #1
Name
ID#
Group#
Subscriber Name
Relationship to Patient
Date of Birth
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SSN #
-
-
Insurance Phone
Pre-Cert #
Insurance #2
Name
ID#
Group#
Subscriber Name
Relationship to Patient
Date of Birth
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2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
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1932
1931
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1929
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1924
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1922
1921
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1914
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1912
1911
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1907
1906
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1904
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1901
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SSN #
-
-
Insurance Phone
Pre-Cert #
PAST MEDICAL HISTORY
*
CAD (Coronary Artery Disease)
PVD (Peripheral Vascular Disease)
Lung Disease
Stroke
Kidney Failure
Diabetes
Pt on Anticoagulant Therapy (ie Coumadin, Plavix, Lovenox, ASA)
Stop Date
Other
None
SURGERY INFORMATION
CPT CODE(S)
*
Surgical Procedure
*
ICD-10 CODE(S)
Surgical Diagnosis
*
SURGEON
Surgeon Name
*
Surgeon Email
*
Scheduled By Email
*
Surgery Length
*
0
1
2
3
4
5
6
7
8
9
10
11
12
(hours)
00
15
30
45
(minutes)
2nd Surgeon
Assisting Surgeon
Type of Anesthesia
Please select
General
MAC
Only Local Only
Ax Block
Bier Block
Gen/Epi
Epi/Spinal
IV Mod Sedation
Choice
Need SA (surgical assistant)
SPECIAL SURGICAL NEEDS
Allergies
Latex
Other
X-Ray:
Portable
C-ARM
Does patient currently have any implantable devices?
*
Yes
No
Pacemakers/AICD-additional information required: Type of pacemaker/implant, Date placed and date of last battery change, Effect of magnet, Cardiology assessment of current function
Type of Implants/Devices
Date
Blood/Contact/Airborne Precautions
Instrument/Equipment/Tables
Patient Position/Device
Please select
Cane Stirrups
Allen Stirrups
Beach Chair
Supine
Prone
Lithotomy
Split Leg
ELECTRONIC SIGNATURE
Physicians Sign
*
Last 4 Digits SSN -
Step 2 of 3
Pre-Operative Testing
Suggested Minimal Pre-Op Tests
These lab tests are RECOMENDED GUIDELINES and NOT STRICT REQUIREMENTS
They may be modified based on patient history and/or surgical procedure.
Hypertension
EKG
BMP
Diabetes Mellitus
EKG
BMP
Men > 45 & Women > 50
EKG
Age > 65
EKG
BMP
CBC
ESRD
EKG
BMP
CBC
All female patients unless menopausal or status post hysterectomy
Urine pregnancy test
Labs
⇒ Labwork within 1 month is acceptable in patients with NO CHANGE IN HEALTH STATUS OR MEDICATIONS
⇒ There is no anesthesia indication for urinalysis
LABS:
ICD-10 Code(s) Required
Albumin
BMP
CMP
CBC w/diff
Free T4
Hemogram
H&H
Hgb A1C
Lipid Panel
Liver Function Profile
Magnesium
MRSA Intra Nasal Screening
Phosphorous
PT & INR
PTH
PTT
Serum Pregnancy (beta hcg.qual)
TSH
Urinalysis
Urine Pregnancy
Urine Culture and Sensitivity
Other
None
Blood Bank
Type and screen
Type and crossmatch
Red blood cells, (RBC)
Red blood cells (RBC) ATTRIBUTES REQUIRED
(units) Transfuse
unit(s) of product
Choose from the following attributes:
No Attributes
CMV Negative
Sickle Cell Negative
Irradiated
Red blood cells, (RBC) autologous
Red blood cells (RBC), autologous
(units) Transfuse
unit(s) of product
Platelets
Platelets, ATTRIBUTES REQUIRED
pheresed unit(s) (1 pheresis = 6-10 units) Transfuse
unit(s) of product
Choose from the following attributes:
No Attributes
CMV Negative
Irradiated
Fresh frozen plasma
Fresh frozen plasma
(units) Transfuse
unit(s) of product
Other products
Other product
(units) Transfuse
unit(s) of product
CARDIOLOGY
ICD-10 Code(s) Required
⇒ EKG within 1 month is acceptable in patients with NO CHANGE IN CARDIAC STATUS
⇒ If a new EKG is not performed, a copy of the MOST RECENT EKG must be faxed to pre-assessment, prior to surgery
EKG 12 Lead
Other
Attach
None
RADIOLOGY
ICD-10 Code(s) Required
⇒ CXR recommended for patients with new cardiac disease, pulmonary disease, > 25 pk/yr smoking history, or recent change in cardiac or pulmonary symptoms. (Stable asthma does not require a CXR.)
DX Chest PA, LAT 2 View
CXR One View
Other
Attach
None
Pre-Op Consultation
Medical - Surgeon's office responsibility to order consult
Anesthesia
Cardiac - Surgeon's office responsibility to order consult
Pulmonary - Surgeon's office responsibility to order consult
Intra-Op Consultation
Pathology
Pre-Surgical Testing
All surgical patients must have pre-operative testing performed per physician's order.
Step 3 of 3
Pre-Op Order #SURGO115
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Outpatient in a bed normal recovery following surgical procedure or intervention
Inpatient Admission (meets medical neccessity for admission)
INPATIENT ONLY
*
Estimated length of stay required for inpatient only
1-2 Days
2-4 Days
>4 Days
ADMISSION CERTIFICATION REQUIRED FOR INPATIENT ONLY
The hospital admission is certified necessary for following reason(s) - if isolation is required, please indicate:
Unit
*
Diagnosis
*
Plan of care: See History & Physical, progress notes and physician orders
Discharge Plan
*
Home with Health Care Provider office follow-up
Home Health Care and Health Care Provider office follow-up
Hospice and Health Care Provider office follow-up
Extended Care Facility (Nursing Home, SNF, Assisted Living)
Allergies
No known allergies
Known allergies/Reaction(s)
Vital Signs
Vital signs - monitor & record upon arrival
Measure temperature when patient arrives to unit
Nursing Orders
Interventions
Active Patient Warming
Evidence
Surgical Preparation
Evidence
No hair removal
Hair removal using clippers
For Total Knee, Total Hip and CABG Patients:
Patient's skin to be cleansed with 2% Chlorhexidine Gluconate (CHG) evening prior and day of surgery
Source
Other
Diet
NPO after midnight
NPO after
NPO except meds after midnight
NPO except meds after
For Contingencies, IV, Fluids and any Medications OTHER THAN Antibiotics
The evidence for the use of preoperative lorazepam is inconclusive
Evidence
Nursing Communication Order
Verify that patient has taken all home medications (including blood pressure and heart medications) with a sip of water prior to arrival to preop unit EXCEPT anticoagulants, oral hypoglycemics and insulin (unless ordered by PCP).
Notify Physician if blood pressure or heart medications not taken prior to arrvial to pre-op unit.
If the patient is currently on a Beta Blocker per their Medication Reconcilliation form/admission orders and has not taken within 24 hours of surgery, this serves as a Physician Order for a one time dose
the morning of surgery
.
Page anesthesia prior to administration of Beta blocker if pulse less than 50 or Systolic BP less than 95.
Nursing Communication Order - Before arrival to pre-op, begin IV
Lactated Ringers 1000 mL at KVO via 18-20 gauge angiocath
Dialysis/Renal Failure Patients
Normal Saline 500 mL bag at 40 mL/hr via mini drip
Pediatric Patients
Lactated Ringers 500 mL @ KVO via 20-24G angiocath
Anesthesia
ADULT Anesthesia Protocol
PEDIATRIC Anesthesia Protocol
General
VTE Prophylaxis
Note: Post-Op VTE Prophylaxis to be ordered on Post Op Orders
For patients without contraindications to anticoagulation who are at moderate to high risk for VTE, administer LDUH or an LMWH for DVT prophylaxis
VTE Prophylaxis Not Indicated
Reason:
Mechanical VTE Prophylaxis
Sequential Compression Device-Apply
Arterial-Venous Booties-Apply
VTE Prophylaxis Contraindicated Mechanical
Dropdown below is required if VTE Prophylaxis Contraindicated Mechanical
Due to lower extremity trauma
Due to patient refusal
Due to continuous IV Heparin 24 hours before/after surgery
Mechanical VTE Prophylaxis Not Indicatedmeets low risk criteria (e.g. ambulating)
Other
Pharmacologic VTE Prophylaxis
Enoxaparin (Lovenox) 40 MG SQ x 1
Enoxaparin (Lovenox) 30 MG SQ X 1 PRE-OP
Contraindications to pharmacologic prophylaxis
VTE Prophylaxis Contraindicated Pharmacologic
Dropdown below is required if VTE Prophylaxis Contraindicated Pharmacologic
Due to active bleeding
Due to risk of bleeding
Due to Heparin induced thrombocytopenia (HIT)
Due to recent intraocular or intracranial surgery
Pharmacologic VTE Prophylaxis Not Indicated meets low risk criteria (e.g. ambulating)
Other
Prophylactic ANTIBIOTICS - For all indicated surgeries EXCEPT COLON and HYSTERECTOMY and UROLOGIC Procedures
cefazolin (Ancef, Kefzol)
2 gram intravenously once if < or = 120 kg over 30 minutes. Infuse 30 minutes prior to incision
3 gram intravenously once if > 120 kg over 60 minutes. Infuse 30 minutes prior to incision
Vancomycin
1 gram intravenously once if < or = 80 kg over 60 mins. Infuse 30 minutes prior to incision.
1.5 gram intravenously once 80-119 over 90 mins. Infuse 30 minutes prior to incision.
2 gram intravenously once if > or = 120 kg over 120 mins. Infuse 30 minutes prior to incision.
Reason indicated:
Other
None
Prophylactic Antibiotics - BETA LACTAM ALLERGY for all indicated surgeries EXCEPT COLON and HYSTERECTOMY
Vancomycin
1 gram intravenously once if < or = 80 kg over 60 mins. Infuse 30 minutes prior to incision.
1.5 gram intravenously once 80-119 over 90 mins. Infuse 30 minutes prior to incision.
2 gram intravenously once if > or = 120 kg over 120 mins. Infuse 30 minutes prior to incision.
Reason for Use: Documentation of beta-lactam (penicillin or cephalosporin) allergy.
clindamycin
900 milligram intravenously once to be initiated within 30 minutes before surgical incision
Other
None
Prophylactic Antibiotics - COLON
ampicillin-sulbactam (Unasyn)
3 gram intravenously once to be initiated within 30 minutes before surgical incision
cefOXitin (Mefoxin)
2 gram intravenously once over 30 minutes. Infuse 30 minutes before surgical incision
Ertapenem (Invanz)
1 gram intravenously over 30 minutes to be initiated 30 minutes before surgical incision.
RHS Restriction to single dose preop for colon procedures (no post-op or treatment doses.
OR
cefazolin (Ancef, Kefzol) PLUS metRONIDAZOLE (Flagyl)
1 gram intravenously once if < or = 80 kg to be used in combination with metRONIDAZOLE (Flagyl) 500 milligram intravenously once & initiated within 30 minutes before surgical incision
2 gram intravenously once if > 80 kg to be used in combination with metRONIDAZOLE (Flagyl) 500 milligram intravenously once & initiated within 30 minutes before surgical incision
Other
None
Prophylactic Antibiotics - HYSTERECTOMY
ampicillin-sulbactam (Unasyn)
3 gram intravenously once to be initiated within 30 minutes before surgical incision
cefOXitin (Mefoxin)
2 gram intravenously once over 30 minutes. Infuse 30 minutes prior to incision
cefazolin (Ancef, Kefzol)
2 gram intravenously once if < or = 120 kg over 30 minutes. Infuse 30 minutes prior to incision
3 gram intravenously once if > 120 kg over 60 minutes. Infuse 30 minutes prior to incision
Other
None
Prophylactic Antibiotics-Beta Lactam Allergy - COLON and HYSTERECTOMY
metRONIDAZOLE (Flagyl) PLUS levofloxacin (Levaquin)
500 milligram intravenously once to be used in combination with levofloxacin (Levaquin) 500 milligram & initiated within 30 minutes before surgical incision
PLUS levofloxacin (Levaquin)
500 milligram intravenously once to be used in combination with metRONIDAZOLE & to be initiated within 30 minutes before surgical incision.
Other
None
Prophylactic Antibiotics for ALL UROLOGIC PROCEDURES EXCEPT Implanted Prosthesis
Ciprofloxacin (Cipro)
500 mg orally once within 30 minutes before surgical incision
400 mg intravenously once within 30 minutes before surgical incision
Azetreonam PLUS
2 gram intravenously once over 60 minutes. Infuse 30 minutes prior to incision
Clindamycin
900 milligram intravenously once over 30 minutes to be used in combination with Aztreonam. Infuse 30 minutes prior to incision
Other
None
Prophylactic Antibiotics for IMPLANTED PENILE PROSTHESIS INSERTION/REMOVAL OR REVISION
Ciprofloxacin (Cipro)
3 gram intravenously once to be initiated with 30 minutes before surgical incision
Azetreonam PLUS
2 gram intravenously once over 60 minutes. Infuse 30 minutes prior to incision
Clindamycin
900 milligram intravenously once over 30 minutes to be used in combination with Aztreonam. Infuse 30 minutes prior to incision
Other
None
Treatment Antibiotics
Additional Orders (Except for Labs, See step 2 of 4)
Noncategorized
Witness Required for Consent
*
Yes
No
Witness consent for:
Other
Code Status:
Full Code
DNR
DNI