MlRALAX / GATORADE BOWEL PREPARATION
Purchase at the pharmacy: 4 Dulcolax (Bisacodyl) 5 mg Laxative tablets
1 Miralax 238 gram bottle
1 Gatorade 64 ounce bottle. All are sold over the counter.
One day before the procedure:
You may have a light breakfast but only clear liquids for the rest of the day.
At 3:00pm take the 4 Dulcolax tabs. with a glass of water.
At 5:00pm mix the whole bottle of Miralax with the 64 oz. bottle of Gatorade.
Shake the solution until the Miralax is dissolved.
Drink an 8 oz. glass every 10-15 minutes until the solution is gone.
Continue drinking clear liquids until bedtime.
***DO NOT TAKE ANYTHING BY MOUTH AFTER MIDNIGHT***
On the day of the procedure:
If you normally take blood pressure medication in the morning, you may take it with a sip
of water the morning of the procedure. Hold all other medications until after the
procedure.
Diabetic Patients:
Day of prep: The morning medication dosage is taken as usual. The afternoon and
evening dose is Yz the usual dose. If you start feeling symptomatic, do an accucheck. If
the results are low, drink clear liquids with carbohydrates.
Day of procedure: Hold all diabetic medications, but take them with you to the hospital.
An accucheck will be done upon your arrival.
o Driving: You cannot drive; use a taxi or a bus after the procedure. You must
have an adult accompany you and drive you home.
You do not have to stop taking blood thinners if you are having a colonoscopy. Please let
us know if you have a defibrillator heart device so that we can notify the hospital. If you
are having surgery please stop blood thinners 5 days before the surgery.
*Clear liquids: Strained fruit juices without pulp, water, clear broth or bouillon, coffee,
tea (without milk or non-dairy creamer), Gatorade, carbonated soft drinks, Kool-Aid,
plainjello without added fruit or toppings, Popsicles and hard candy. Nothing colored
red or purple.
Please call our office if you have any questions. 512-418-1979
Hospital:
Date of procedure:
r _
_
_
Arrival time:
---------
Magnesium Citrate Bowel Preparation
Instructions
Purchase: 2 ten ounce bottles of Magnesium Citrate (green) which is sold over the
counter at the pharmacy.
The day before your procedure
you may have a regular diet for breakfast and lunch.
of the day and evening.
_
Only clear liquids for the rest
At 1:00 pm drink 1 ten ounce bottle of magnesium citrate followed by 3 eight ounce
glasses of any clear liquid. Stay close to the toilet facilities.
At 6:00 pm drink 1 ten ounce bottle of magnesium citrate followed by 3 eight ounce
glasses of any clear liquid. Stay close to the toilet facilities.
It is very important to drink all the liquid with each dose of laxative in order to have
an adequate bowel preparation.
Clear Liquids Allowed: Water, clear fruit juice, coffee, tea, sodas, gelatin, popsicles,
beef or chicken bouillon broth, hard candies. No milk products or solid food.
DO NOT DRINK ANYTHING AFTER MIDNIGHT.
If you normally take heart or blood pressure medication in the morning, you may
take it with just a sip of water the day of the procedure. Hold all other medications
until after the procedure.
Please let us know if you are taking a blood thinner or Plavix or if you have a
diffibulator.
If you have any questions, please call the office (512) 418-1979 ext. 222 during
regular business hours. After hours call Medlink at (512) 323-5465
DATEOFPROCEDURE:
_
FACILITY:
_
TIME OF PROCEDURE:
ARRIV AL TIME:
_
INSTRUCTIONS FOR COMPLETE BOWEL PREPARATION
John S. Mangione, M.D
Robert W. Cline, M.D.
William G. Robertson, M.D.
DAY
BEFORE
(512) 418-1979
(512) 418-1763
(512) 418-1755
4106 Medical Parkway
Austin, Texas 78756
Fax Number: (512) 418-1943
SURGERY:
You may have a regular breakfast and a light lunch. Full liquids only until 6:00 p.m.
Clear liquids only until midnight. You may have hard candy, clear broth, and carbonated
beverages, clear fruit juice, coffee tea, Jell-O and Popsicle.
At
take the two Bisacodyl (Dulcolax) tablets.
At
start drinking the PEG solution. Drink ten ounces every ten to fifteen
minutes until stools are clear. The liquid stool should be clear. This does not mean
colorless, an appearance of yellow or green without stool particles is normal. Usually
about one-half of the solution needs to be taken. If you feel excessively full, distended or
nauseated, temporarily hold off of the solution until this passes. Then resume. You may
mix the PEG solution and refrigerate it for several hours before drinking. To enhance the
taste, try sucking on hard candy. If you think you are having trouble tolerating the PEG
solution, call the doctor before deciding not to drink the remainder. After completion of
the PEG solution, you may have clear liquids only.
It is very important to follow the diet and laxatives to assure you have an adequate prep.
Please do not drink anything after
before you surgery or examination. You may
take any necessary medications with a sip of water. If you take diabetic medications or
blood thinners, please read the enclosed flyer. You need to arrange for someone to stay
and drive you home from the hospital.
DAY OF SURGERY:
Be at the hospital two hours before your surgery time.
If you have a colonoscopy, plan to stay at home for the remainder of the day after the
examination. Eat a normal diet. There will be no limitation of activity or food the
following day.
If you have abdominal surgery, follow the instructions you are given upon your
discharge from the hospital.
If you have any question or problems with the instructions, please contact your doctor's
office, or ifit is after hours, MedLink 512-323-5465
Facility where procedure is scheduled:
Date procedure is scheduled:
Arrival time at Facility for procedure
_
OUT PATIENT PRE-OP INSTRUCTIONS
HOSPITAL:-------------DATE OF SURGERY:----------ARRIVALTIME TO HOSPITAL:------For your procedure you will need to purchase 2 Fleet
Enemas (green box) which are sold over the counter at
the pharmacy or grocery store. Use both of the
enemas 1 Y2 hours before leaving to go to the hospital.
If you are having surgery please discontinue all blood
thinners (aspirin, Ibuprofen, Coumadin, Plavix) 5 days
before the surgery date. You do not have to stop blood
thinners if you are scheduled for an endoscopy
procedure. If you are diabetic do not take your
morning medication but take it with you to the
hospital. They will do an accucheck upon your arrival.
Do Not Eat Or Drink Anything After Midnight except
for heart or blood pressure medications on
Please call me with any question's you may have about
the procedure.
:Nancy
418-1979
ext.
222
RE1WARKABLE COlvllENIEVCE
DIRECTIONS
At Bailey Square Surgery Center, we
ofthe Bailey Square Medical Building at II r I West 34th Street
offer a remarkable
convenience
by allowing
our patients to easily provide their online
clinical history by visiting our website ..
is
Bailey Square Surgery Center is located on the fourth floor
at Medical Parkway, just across from Seton Hospital.
FREE PARKING
There
available in front of the faclllry,
Please go to:
www.baileysquare.com
and click on Online
Clinical History. Once you do, you will be able
to enter your clinical history into an online form.
By providing this infor-mation online, the amount
of paperwork
needed
on the day of your
admission is greatly reduced and you are assured
of the accur-ate documentation
of your clinical
history. It's remarkably convenient!
It will take approximately
10-30 minutes to
complete the Online Clinical History Form,
depending on your medical history.
Before ),ou begin, take a moment to be sure
)IOU have the following
information on hand.
.!. The name of your doctor who is admitting
you to the surgery center
.:. The date and time of your scheduled
procedure
.:. A short description
of the procedure
.:. The name of the person
dr-iving you home
.;. The name of the person
you after the procedure
who wili care for
.:. The name and dosage of ALL of your
medications
.~. The dates and descriptions
of past surgeries
S'fDavid's
BAILEY SQUARE
SURGERY CENTER
I r I r West 34th Street, 4th Floor
Austin,Texas 78705
Tel 512.454.6753 .:. Fax 512.454.4314
www.baileysquare.com
For your convenience,
our facility is a
"WIRELESS HOT SPOT"
, Any complaints may be directed to tho
Administrator
of Bailey Square Surgery
Center at (512) 454-6753. If this venue
does not provide you with an acceptable
resolution, the Texas Depmtment of Health
is the responsible agency for ambulatory
surgical center complaint investigations.
Any complaints
may be submitted
to:
Director, Texas Department
of Health,
Health
Facility
Compliance
Division,
1100 West 49th Street, Austin, Texas
78756, 1-888-973-0022.
stDavid's
BAILEY SQUARE
SURGEIZ¥ CEN'.f'ER
'1'1'11West 3'~th Street·
TE\. 512AG't6lG3
Austin, Texas liliO!)
[0(1)<. G12.'\G(~A3'14
Your physician has an ownership interest
in Bailey Square Surgery Center.
!!f Yes
Medicare Ombudsman contact:
1-800-MEDICARE
www.cms.hhs.gov/center/ornbudsman.asp
0
No
Patient's Rights
Square Surgery
human rights
of
patients.
Efforts
are directed
to providing care
commensurate
with those basic human rights.
The staff
Center
I3SS-S04 P (OtJ/09)
and personnel
recognize
the
of Bailey
basic
Patients
are treated
with ruspoct,
consideration,
and dignity.
Patients
are provided,
to the de9reE~
.known,
complete
inforruatlon
concerning
their
diagnosis,
treatment,
unci proqnosis. Wlwn it is
medically
lnadvisable to give such information
to
a patient, the information is provided
to a person
Jesi~Jl)ated
by thfJ patients or to <liagaliy authorized
rersol),
Patients
are provided
appropriate
privacy
of any information
or treatinent
concerning
his/
her own medical care. Patients have the right to
be informed
of <:II)Y persons
other' then routine
personnel that would be observing or' pnrticipatinq
in his/her
treatment,
Patient disclosures
and
records are trealed
confidentially,
and, except when
required
by law, patients
are given the opportunity
to iJfJprove or reFuse their relaase.
Patients are given
the opportunity
to partlcipato
in decisions
involving
their health care, except when such participation
is
contraindicated
for medical
reasons.
Patients
have
the right to change primary or specialty
physicians
iF
other qualified physicians
are available,
';
Patients have the right to:
person
know the
coordinatinq
or persons
his/her care,
responsible
receive
from
his/her
physician
enough
information
so that he/she may understand the
procedure. 01' tron tmont being received in ordor
to sinn Ihe infonucd
•
•
•
of
know if allY rosourch will be done dllrillg
treatment ami have tlw riUht to refuse.
his/her
~1I)(.1
of his/her
ill advance
the oxpoctod
ostil1latfJci
of hi~/her bill. Pationts h~1V0. the right to
know what lLlill!Y SqU<11'OSur~Jery Center rules
and re~JLrI(1tioIlS apply to his/her conduct and
respol1sibiliti(~!; <15 a patient.
know
,1I\1OUllt
•
know. rnothods
for oxpressinq grievances
suUgcstion:; lo U,1 lloy SCJLwre Sur~Jcry Center,
•
infonnatlonconcerulnq
the
institution
it is the patient's responsibility
or physician for clarillcation.
to
(1I1SWer all medical
questions
best of his/her knowledge.
truthfully
nurse
the
to the
and
to which
instructions.
•
arrange
for a responsible
adult to provide
transportation
to and [rom Balloy Square.
Surgery Center, and remain with tho patient for
period of at least 24 hours ,lfter surgery, or as
directed
and appropriatn
with the medications
and/or anosthetlcs
he/she will bo rcceivlnq.
carufully
and follow th\.l pos t-oporatlve
instructions
he/she receives from the physici'Hl(s)
and/or
nurses.
This includes post-operative
appointmon
ts.
read
contact
he/she may have) to be transferred, The
his/her
complications.
to which the
give approval
staff, as well
patient is baing
prior to transfer.
ask
carefully and follow tho pre-operative
instructions received [rom his/her physician and/
or Gailey Square Surgery Center unci notify the
Center if he/she has not followed 'pre-operiltivn
service from the fndlity.
of mnchauism by which he/5he will
have continuinq
henlth care followillg discharge
from this surg(HY contur.
and receive <111f)XI)lc\Jliltioll
of source of payment.
to:
rond
bo informed
examine
responsibility
rend ancl undersrand all permits and/or CVI15ents
he/she siqns. If tho patient does not understand,
the
bill·reg,lrcJless
•
It is the patient's
consent.
refuse treatment
unci to be informed
consequences
of his/her actions,
expect quality care
•
Patient's Responsibilities
for
institution
tri.lnsferrcd must
b~ respectful
if
physician
of HII the hcalthcare
as
has
he/she
ilily
providers and
other patients.
•
b!~ assured
the) t mmketinn
or udvHrtising
rcgardill9
the corupe tenco and capabilitles
of
this facility and its org<1l1iLdtlOIlis not misleading
to patients,
for service rendered aro in
a timely basis and ultimate responsibility is his/
hers, reg<1l'dless of whatever insurance coverage
he/she may have.
•
an advanced dlroctivo (such as living will,
h~)alth cao proxy, or durable power of attorney
for health
carol concerning
treatment
or
desigllCltill9 a surrogate decision maker with tho
expectation
that the facility will honor the intent
of that directive
to the extent
permitted
by law
and facility policy.
notify
•
have
disclosure mgiJrdil19 physician financial
or ownership in the Surgery Center.
in teres t
assure nil payments
tho Administrator,
Director
of
Clinical
Services, Director of Business Services or their
designee at Balloy Square Surgery Center if
he/she feels any rights have been violated,
has il signiFicimt complaint
or a suggestion
to
improve services 01' quality of care. This can
be accomplished
by filling out our Patient
Questionnaire 01' by direct contact.
"