Informed Consent for Surgery or Treatment
Patient: Date of Birth:
1. I hereby request and authorize Marcelo Hochman, MD, his assistants, and operating room personnel to perform upon me:
On or about the date of:
______
In general, the purpose of the procedure is:
2. Dr. Hochman has fully explained, in terms clear to me the operation(s) to be performed, foreseeable risks involved, alternative methods of treatment, as well as what I can expect if surgery is uneventful. I further acknowledge that I have been given an opportunity to ask any questions I desired and that these questions have been answered to my satisfaction. Initial______
3. Dr. Hochman has fully explained, in terms clear to me the specific and pertinent risks associated with my procedure. I acknowledge that I have been given an opportunity to ask any questions I desired regarding these specific risks and that these questions have been answered to my satisfaction. Initial______
4. I also authorize Dr. Hochman to perform any other procedure(s) or take whatever measures he may deem necessary or desirable, in addition to or in substitution for the surgical procedures initially contemplated. Initial______
5. I have been advised that the object of the operation I have requested is improvement in my condition, not perfection; that there is a possibility that imperfection might ensue, and that the result might not live up to my expectations or the desired goals that have been established. I acknowledge that no guarantee has been made by anyone regarding the procedure that I have herein requested and authorized. Initial______
6. I have been advised that any incisions made in the skin will leave permanent scars. The extent and location of these scars have been described to me. I have also been advised that scars may take up to one year to mature and the changes that normally occur in their appearance during the healing period have been described to me. Initial______
7. I have been told that a medical grade implant may be used in the above-mentioned procedure and have been advised of the risks as well as alternative forms of treatment. Initial______
8. I have been informed that the above procedure may require that transplantation of tissue, cartilage, or bone from other areas of my body. Initial______
9. Dr. Hochman has fully explained to me, in terms clear to me, the effect of the local anesthetics that may be used for my operation. Initial______
10. I understand that if Dr. Hochman judges at any time that my surgery should be canceled for any reason, he may do so. . Initial______
11. I agree to follow the instructions given to me by Dr. Hochman to the best of my ability before, during and after surgery. Initial______
12. I hereby state that the information I furnished to Dr. Hochman during my comprehensive pre-operative evaluation is complete and correct and that I have disclosed all my known medical conditions, allergies, or adverse reactions to medical preparations. Initial______
13. I hereby state that I have quit smoking for at least 3 weeks before my operation and will continue to refrain from smoking for at least 3 weeks after. Initial______
14. I hereby grant consent for my blood to be drawn and tested if a staff member incurs an accidental needle stick or wound during my procedure or medical treatment. Initial_____
15. If a laser is being used for my procedure I have been advised of the specific and pertinent risks associated with laser procedures. Initial_____
Date: ______Signed: ______Relationship to patient: ______
Patient or Representative
______
Marcelo Hochman, MD Witness:
Surgery Patient Check-In
Name: Claire Perrill DOB: 1/17/1948
Date______Arrival Time______
Procedure______
Name of caregiver & #______
Patient Pick up W & C or WMW
o Name and DOB verified ____
o Consent up to date ____
o Allergies verified ____
o NPO? ____
o Contacts removed ____
o Dentures removed ____
o Hearing Aids “ “ ____
o Make up removed ____
o Post –Op care sheet given & reviewed ____
o Medicines reviewed ___
o Any meds taken at home ___
o Any additional rx’s given ___
o Patient states understanding of all instructions ___
Patient pre-medicated with the following meds @ ______
o Cephalexin 500mg #_____
o Clindamycin 300mg #_____
o Diazepam 5mg # _____
o Hydrocodone 5 mg #_____
o Oxycodone 7.5/325mg # _____
o Promethazine 25mg # _____
o Prednisone D #_____
o Odansetron # ______@ ______
o Chlorhexidine Gluconate mouthwash _____
o Acyclovir 800 mg _____
o OTHER______
Nurse X:______
MD X:______
SURGICAL RECORD
Date______Patient Name:Claire Perrill DOB: 1/17/1948
Patient name and DOB confirmed: Yes No
Allergies:______NPO Status:______
Patient alert & oriented to person, place, and time: Yes No
Operative site verified: Yes No; Coincides with informed consent: Yes No
Time in OR:______Anesthesia Start:______Procedure Start:______Procedure End:______
Pre-op Diagnosis:______
Post-Op Diagnosis: ______
Procedures(s):______
TIME-OUT Yes No
Surgeon: Dr. Marcelo Hochman
Anesthesiologist: ______Other:______
Scrub Nurse:______Circulator:______
Wound Class: I II III IV
Specimen sent: Yes No Coastal Maize ______
Skin Prep: Technicare/ Water Betadine other______
Positioning: Beach Chair Elbows padded bilaterally soft wrist protectors in place for duration of procedure Blankets applied over torso and lower extremities. Other: ______
SCD’s #EA415748
Electrosurgical Unit: Ellman Surgitron 4.0 Dual RF P/N 2480234 Settings:______
Grounding pad-Site:______Skin integrity intact: pre-op post-op
Vital Signs: (NIBP/Pulse/O2 Sat)
Pre-Op:______Intra-Op______
Post-Op______
Sponge/ Sharps Count Correct: Initial: Yes No; If No, action taken:______
Closing: Yes No; If No, action taken:______
Implant Record: Type/ Reorder number/ Lot number/ Manufacturer/ Size
______
Meds: NS 500cc Sterile Water 500cc Lidocaine 1% with epi. Betadine
Vaseline Surgicel Kenalog 40mg Tetracaine ½ 0/0 gtts Maxitrol ung Marcaine
BSS Afrin Nasal Spray Other______
Drains Yes No Type and Location:______
Dressing: Telfa 2x2 drip pad under nose Glasscock Dressings Xeroform 4x4
Kerlix Co-flex Tape Nasal Splint Compression Garment
Other ______
Location:______
*Patient discharged in satisfactory condition via W/C to personal ride
*Discharge Instructions Reviewed & Post-Op Appointment given to patient Caregiver
______
Signature Date
Procedure Note
DATE:
PATIENT NAME: Claire Perrill BIRTHDATE1/17/1948
DIAGNOSIS:
SITE/LESION/PROCEDURE CONFIRMED W/PT. YES N/A
NAME AND BIRTHDATE CONFIRMED W/PT. YES N/A
Laser Eye Shields/Goggles placed and removed by MD
YES N/A
PROCEDURE:
FINDINGS:
SUTURE:
ANESTHESIA: ½ % lidocaine with 1:200,000 epinephrine
1 % lidocaine with 1:100,000 epinephrine
TIVA
RECOVERY FORM
Date:______Patient Name:Claire Perrill Date of Birth:1/17/1948
Procedure: ______
Allergies:______
______
Assessment
Circle One
Circulatory / Pink / Warm / Cool / Clammy / Other (See Notes)
Dressing / Operative Site______Dry & Intact Other (See Notes)
IV Therapy: Fluid______Site:______Amount: ______
Patent, Dry, Intact, No Redness or Edema Noted Other (See Notes)
Level of Pain:______
______
Vital Signs
______
**Medications given – see anesthesia record**______
______
______
Plan of Care / Interventions
Potential Alteration in Mental Status Reoriented to Time and Place
Potential for Fear / Anxiety Oriented to Environment Questions Answered
Potential Alteration in Comfort Repositioned for Comfort Level of Pain ____
Pain Reevaluation if Meds Given ______
Potential for Injury Never left unattended Assisted to the bathroom
Brakes locked when transporting
Potential Alteration in Fluid Volume PO Fluids given Assess for Nausea
Knowledge Deficit Review post-op instructions with pt and caregiver, including after hour provisions Post – op Appointment
______
Discharge Evaluation
Vital signs at preoperative level Minimal or No Pain Minimal or no Nausea
Dressing Dry and Intact if applicable Able to Bear Weight Responsible Adult to accompany pt home
______
Discharge
Discharge @______Via Wheelchair Other (See Notes)
IV d/c @______
______
Nursing Notes
______
______
______
______
Nurse’s Signature:______