Ambulatory Surgery
Trans-in from Surgery-OPD; ambulatory and accompanied by relative, conscious and coherent; not in
cardiopulmonary distress; on nothing per orem; with orders for AVF creation by Dr. Gonzales under local
anesthesia ; with OR proposal; with consent for surgery signed and secured.
Patient identified and verified correctly. Checked for proper OR attire and allergy. Wheeled to OR
theater.
Intraoperative health care and management
D> for AVF creation
Assessment done; patient’s identity and OR procedure verified; prepared for transfer to OR complex;
wheeled to OR3 safely and securely; placed patient to OR table; hooked to cardiac monitor, BP cuff and
pulse oximeter; surgical safety checklist utilized; time-out done by SROD ; skin preparation rendered;
sterile drapes applied; sterility maintained at all times; all needs of OR team attended.
H> Local anesthesia given by Dr.
H> OR procedure started by Dr.
H> Specimen out and saved for histopathology and laboratory work-up.
H> OR procedure ended; sterile dressing applied; fixed patient and prepared for discharge.
For discharge
With orders for discharge verified and carried out.
Assessment done; informed patient on discharge orders; advised relative on discharge process and settling
of accounts; facilitated all documents necessary for discharge; safety and comfort measures maintained at
all times; all health needs attended; monitored accordingly while still at the OR.
Discharged in good condition; ambulatory and accompanied by relative; health teachings regarding rest
and activity restrictions rendered; instructed on home medications; advised to return for follow-up checkup at Surgery OPD.
Hernial sac appear thickened/edematous ending distally as a blind ended pouch. No noted contents on
opening of the sac. No bleeding prior to closure.
EBL=minimal