WRHA Surgery Program

PREoperative Assessment Patient Questionnaire

July 2010

Carol Knudson

WRHA Perioperative Nurse Educator

PreamblePreamble• Questionnaire development was a collaborative effort by Questionnaire development was a collaborative effort by

the WRHA Surgery Program and PACthe WRHA Surgery Program and PAC

• Facilitates the collection of consistent patient Facilitates the collection of consistent patient information across surgical sites within the region.information across surgical sites within the region.

• Promotes patient safety, enhances quality of patient Promotes patient safety, enhances quality of patient care and service delivery to the patient population we care and service delivery to the patient population we serve.serve.

• NOTE: Replaces the Patient/Nursing database for the NOTE: Replaces the Patient/Nursing database for the elective surgery patient population.elective surgery patient population.

Purpose

• Collect information from patients coming for elective surgery.

• Information from questionnaire will be reviewed by PAC nurse to determine if additional information, assessments or testing is required prior to surgery.

General Information

• To be completed by ALL surgical patients (including Day Surgery Patients) scheduled for Elective surgery EXCEPT: orthopedic total joint hip and knee arthroplasty.

• To be completed and MAILED or DROPPED OFF at the surgeon’s office AT LEAST THREE (3) WEEKS PRIOR to the surgery date.

• Will be included in the PAC package and is intended to be circulated to the patient by the surgeon/office.

• Completed questionnaire required in order to slate the surgical procedure.

• Right side intended for documentation by the nurse and is for “Hospital Use Only”

• Completed questionnaire is dated, signed and placed in the patient health record and becomes part of the permanent health record.

• Personal Health Information Number (PHIN)

• Legal Name (as found on Provincial Health Card)

• Preferred Name

• Date of Surgery (DD/MMM/YYYY)

• Surgeon’s Name

• Type of Surgery

Patient to IndicatePatient to Indicate

• Health Care Directive (copy attached)

• Information related to language spoken and understood

• Contact person including relationship and phone #

• Name of person picking up from hospital on discharge including relationship and phone# (required for patients receiving general Anesthetic or Conscious Sedation)

• Indication of hospitalization in the past six(6) months for MRSA VRE TB/Alert C-diff Other

• Allergies or sensitivities

• Medic Alert® Bracelet including reason for wearing

• Medications including prescription drugs, over-the-counter drugs, herbs, or other

• If coming to PREoperative Assessment Clinic, patient to bring containers of all prescription and over the counter medications

• Family Doctor’s name, phone number, Family Doctor’s name, phone number, date, and reason for last visitdate, and reason for last visit

• Specialist Doctor’s name, phone Specialist Doctor’s name, phone number, date, and reason for last visitnumber, date, and reason for last visit

• Possibility of pregnancyPossibility of pregnancy

• Height and Weight

• Obstructive Sleep Apnea (OSA) Risk questions replacing OSA Risk Identification and Risk Assessment in Perioperative adults form #W-00255

Patients to indicate “yes”/“no” to the following: Do you have OSA? Have you been told that you have OSA? Do you snore loudly (loud enough to be heard through

closed doors?) Do you think you have abnormal or excessive sleepiness

during the day? Has anyone noticed that you momentarily stop

breathing during your sleep? Is your neck measurement greater than 40cm?

• Shortness of breath or tightness in the chest ifLying flat in bedWalking 1 blockClimbing 1 flight of stairsHousework, getting dressed

• Health History including:

Chest pain Angina Heart attack CHF Heart murmur Fast/skipped heart

beat Rheumatic fever High Blood Pressure Diabetes Persistent swelling in

feet of legs Lung problems SOB, cough, wheezeSOB, cough, wheeze OSAOSA Home oxygenHome oxygen

CPAP/BiPAP machineCPAP/BiPAP machine StrokeStroke TIA/mini-strokeTIA/mini-stroke Migraine/headacheMigraine/headache Blackouts/fainting Blackouts/fainting

spells in past yearspells in past year SeizuresSeizures Recent memory lossRecent memory loss Disease of nervous Disease of nervous

systemsystem Parkinson’s diseaseParkinson’s disease Muscle diseaseMuscle disease Joint/bone problemsJoint/bone problems Chronic painChronic pain Falls within 6 monthsFalls within 6 months GoutGout Frequent heart burnFrequent heart burn UlcersUlcers

Hepatitis/jaundice/liver Hepatitis/jaundice/liver diseasedisease

Bowel diseaseBowel disease Kidney/bladder problemsKidney/bladder problems HemodialysisHemodialysis Peritoneal dialysisPeritoneal dialysis CancerCancer HIV/AIDSHIV/AIDS Anemia/Low IronAnemia/Low Iron Blood TransfusionBlood Transfusion Bleeding ProblemsBleeding Problems Sickle Cell DiseaseSickle Cell Disease Blood Clots (legs, lungs, Blood Clots (legs, lungs,

pelvis)pelvis)

GlaucomaGlaucoma Thyroid ProblemsThyroid Problems Mental Health IssuesMental Health Issues DementiaDementia DepressionDepression Anxiety/Panic AttacksAnxiety/Panic Attacks Malignant HyperthermiaMalignant Hyperthermia Pseudocholinesterase Pseudocholinesterase

DeficiencyDeficiency Implanted Electronic DevicesImplanted Electronic Devices Other Other Health Problems that run in Health Problems that run in

familyfamily

• Received or had problems with anesthetic

• Family member had problem with anesthetic

• Previous surgeries including date and hospital

• Admission to hospital for reasons other than surgery including date, reason for admission and hospital

• Special tests including name of the test, date, and hospital Examples include Stress Test, Ultrasound, and

angiogram

• Transfusion History including rare blood type objection to receipt of transfusion previous transfusions indicating any problems

• Smoking History including amount smoked per day number of years smoked when quit (if applicable)

• Alcohol consumption including amount and how often

• Use of recreational drugs including amount and how often

• Having any of the following: Capped or Loose Teeth Contact Lenses Eyeglasses Dentures Hearing Aid Body Piercings Other (examples artificial limbs or artificial eye)

• Nutritional Status including:Nutritional Status including: Type of dietType of diet Difficulty eating or swallowingDifficulty eating or swallowing Weight gain, loss including amount and over what Weight gain, loss including amount and over what

time periodtime period Nausea, vomiting, choking, indigestion, reflux, Nausea, vomiting, choking, indigestion, reflux,

anorexiaanorexia

• Elimination Pattern includingElimination Pattern including OstomyOstomy Urinary pattern (urgency, incontinence, frequency, Urinary pattern (urgency, incontinence, frequency,

nocturianocturia Bowel pattern (diarrhea, constipation, incontinenceBowel pattern (diarrhea, constipation, incontinence Other (example catheter)Other (example catheter)

• Functional status with explanations Functional status with explanations including:including: Changes in activities of daily livingChanges in activities of daily living Assistance required for toileting, bathing, Assistance required for toileting, bathing,

dressing, walkingdressing, walking Use of crutches, cane, walker, wheelchair, Use of crutches, cane, walker, wheelchair,

scooter, mechanical lifts, bathroom assistsscooter, mechanical lifts, bathroom assists Any changes to sleep patternAny changes to sleep pattern Pain including description of intensityPain including description of intensity

• Living arrangements including:Living arrangements including:Lives alone, with spouse/partner, Lives alone, with spouse/partner,

child(ren), pets, otherchild(ren), pets, otherLives in an apartment, house, group Lives in an apartment, house, group

home, PCH, supportive housing, home, PCH, supportive housing, assisted livingassisted living

Use of stairs including number and Use of stairs including number and whether railings presentwhether railings present

• Use of community services including:Use of community services including: Home CareHome Care DietitianDietitian Handi-transitHandi-transit PhysiotherapyPhysiotherapy Day HospitalDay Hospital Occupational TherapyOccupational Therapy Lifeline®Lifeline® Treaty Number and Band NameTreaty Number and Band Name Social Assistance including case#, case Social Assistance including case#, case

worker name and phone#.worker name and phone#.

• Difficulties related to hospitalization Difficulties related to hospitalization including an explanation:including an explanation: At homeAt home At workAt work With financesWith finances OtherOther

• Date and name of person completing Date and name of person completing questionnairequestionnaire

Nurse completes section Nurse completes section Hospital Use OnlyHospital Use Only

• Completed based on information gathered Completed based on information gathered during patient assessmentduring patient assessment

• Patient vital signs:Patient vital signs: TemperatureTemperature PulsePulse Respiratory RateRespiratory Rate Blood Pressure – indicate left or right armBlood Pressure – indicate left or right arm OO2 2 SATSSATS

• Indicate that Medication Reconciliation Indicate that Medication Reconciliation completedcompleted

• Indicate Height (cm) and Weight (kg)Indicate Height (cm) and Weight (kg)

• Calculate BMI (refer to chart or calculate as Calculate BMI (refer to chart or calculate as Weight in kg/Height in mWeight in kg/Height in m22

• Determine patient risk of OSA based on Determine patient risk of OSA based on response to OSA questions and reference to response to OSA questions and reference to laminated poster “Guidelines: OSA laminated poster “Guidelines: OSA Interpretation of Risk ScoreInterpretation of Risk Score Known OSA (PAC referral required)Known OSA (PAC referral required) High Clinical Suspicion (PAC referral required)High Clinical Suspicion (PAC referral required) Low Clinical Suspicion Low Clinical Suspicion

• Indicate if consults have been initiated and if Indicate if consults have been initiated and if so whereso where

• Indicate if Risk for Falls ProtocolIndicate if Risk for Falls Protocol

• Indicate any other pertinent information Indicate any other pertinent information gathered from the patient during the gathered from the patient during the assessment in the space allottedassessment in the space allotted

What happens with questionnaire What happens with questionnaire once returned to surgeon office?once returned to surgeon office?

• Surgeon’s office forwards Questionnaire, Surgeon’s office forwards Questionnaire, Booking Request Form, HX & PX, all Booking Request Form, HX & PX, all completed tests and Consent Form to completed tests and Consent Form to PAC.PAC.

• Complete package is triaged by Complete package is triaged by cliniciansclinicians

• Patient is contacted by phone if Patient is contacted by phone if clarification is requiredclarification is required

• PAC books clinic appointments and notifies PAC books clinic appointments and notifies patient of same (if applicable)patient of same (if applicable)

• At clinic appointment, nurse documents any At clinic appointment, nurse documents any additional information on the right-hand side of additional information on the right-hand side of the questionnaire.the questionnaire.

• Nurse required to sign and date questionnaire. Nurse required to sign and date questionnaire. NOTE: Questionnaire is part of the patient’s NOTE: Questionnaire is part of the patient’s health record.health record.