Assessment for Surgery

Policy

We carefully assess a patient's need for surgical services before offering the patient surgery.

Most patients undertaking surgery are enrolled at the practice, and their health information is available in Medtech.

Non-enrolled patients complete a casual patient form before their initial appointment. If a patient has been referred by their GP, we provide the patient's referring clinician with information relating to their care.

All stages of the patient's treatment are recorded in the patient's clinical record in Medtech.

Before offering surgery

• Assess the patient and determine whether a procedure is required and appropriate.
• Discuss payment options and ask whether the patient has health insurance.
• Assess the patient for clinical risks, e.g. bleeding, infection, abnormal scarring, function, and allergy.

After surgery has been offered and accepted

• Complete a health questionnaire.
• Complete an anaesthesia consultation and pre-assessment, if required.
• Give the patient instructions about their procedure, including:
  • fasting instructions if appropriate
  • post-operative limitations.
• Discuss the return/disposal of surgically removed tissue if appropriate, and record any requests in the patient's record.
• Ensure the patient has appropriate post-surgery support available, and that their place of residence for recovery is within an appropriate distance from clinical assistance.
• Advise the patient about their ability to drive after the procedure:
  • If the surgery is minimal, the patient can drive themselves.
  • If the surgery may compromise the patient's ability to drive, ensure the patient arranges for someone else to drive them home.
• Discuss any post-procedure medication required, including instructions for use.
• Book the patient's procedure, and any follow-up appointments as appropriate (e.g. changing dressing, discussing histology etc.).
• Ensure payment has been discussed, or any pre-approval application has been completed if patient is insured.

Pre-Surgery Patient Information

We can link to any information you give patients prior to surgery.

For example:

• Patient information sheet
• Pre-operative checklist
• Wound care instructions