SURNAME: __________________________ NHI: ________________
FIRST NAMES: ____________________________________________
Clinical Pathway Elective
DATE OF BIRTH: _______/______/_______ SEX: ________________
Laparoscopic Cholecystectomy
Please attach patient label here
□ Elective
□ Lap Cholecystectomy booked
Date Pre-admission: ______________Date of Admission: ______________ Date of Surgery: ______________
INDICATIONS: □ Biliary Colic
□ Cholecystitis
□ Jaundice/Choledocholithiasis
□ Cholangitis
□ Biliary Pancreatitis
□ Gal bladder polyp
Other:
________________________________________________________________________________________
________________________________________________________________________________________
PREADMISSION CHECK
Date:
BASELINE OBSERVATIONS
Temp:
FBC:
Pulse:
U & Es:
B/P:
LFT’S:
RR:
INR:
O2 Saturations = % on air
G & H:
WT:
ECG (if Cardiac Hx or over 45)
CXR
Previous MRSA? /lives in R/H, P/H (take MRSA swabs):
Interpreter required: □ No □ Yes. Language: ________________ Booked (date / time): ________________
RACS information sheet given: □ No □ Yes
Medication: see Admission to Discharge Planner (CR2047)
If no Warfarin, Clopidogrel, Aspirin etc, instructions given
Last day for above medication (name and date):
Replacement medication plan:
If no diabetic meds instructions given, check for other antiplatelet preparations e.g. Arnica, Garlic,
Ginko
Al ergies: _______________________________________________________________________________
□ H/S assessment done (refer Admission to Discharge Planner - CR2047)
Sign: ____________
□ Consent form signed
Sign: ____________
□ Anaesthetic consent signed
Sign: ____________
□ Nursing assessment in Admission to Discharge Planner complete
□ Information given re discharge time (i.e. 11:00 am day after surgery)
□ Transition lounge explained
Name: _____________________
Signature: __________________
Date: ____________________
ORDA (Operating Room Day of Admission)
Date: ______________________________________
Time: ___________________________________
PREPARATION
□ Pre-op checklist complete
□ Clexane given / charted
□ Usual morning meds taken
□ Diabetic meds withheld
□ If no Aspirin / Warfarin, last taken at:
□ Clothes in bag
□ Valuables signed off
□ OR notified
AVAILABLE
□ USS report
□ ERCP report
ORDA nurse’s name: ___________________________
Signed: ___________________________________
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SURNAME: __________________________ NHI: ________________
FIRST NAMES: ____________________________________________
Clinical Pathway Elective
DATE OF BIRTH: _______/______/_______ SEX: ________________
Laparoscopic Cholecystectomy
Please attach patient label here
OPERATION NOTE
Date: ________________________________________ Time: _______________________________________
Surgeon: _____________________________________ Assistant: ____________________________________
Findings: ____________________________________________________________________________________
Anaesthetist: _________________________________________________________________________________
Procedure: __________________________________________________________________________________
____________________________________________________________________________________________
Name: _______________________________________ Signature: ____________________________________
ON WARDING (tick or circle as appropriate)
Date: ________________________________________ Time: ________________________________________
□ Cal bel within reach
□ Patient orientated to ward
□ Patient orientation folder
□ Paracetamol given
□ ½ hourly vital signs commenced and within normal limits
(record on observation chart) Pain Score:
1
2
3
4
5
6
7
8
9
10
Wound bleeding:
□ Nil
□ Minimum
□ Moderate
□ Heavy
Nausea:
□ Nil
□ Minimum
□ Moderate
□ Severe
Drain Amount:
□ Nil
□ Minimum
□ Moderate
□ Large
Type:
□ Haem
□ Serous
□ Bile (report any bile to team)
Site:
□ Not leaking
□ Stitch intact
□ Dressing intact
Tubing:
□ Not kinked
□ Securely attached, taped to body 8-10cm from site
Name of receiving nurse: ________________________
Signature: _________________
Time: ___________
Notes
(Post-op problems should be commented on below) : _________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Name: _______________________________________ Signature: ____________________________________
DAY OF SURGERY
Date: __________________________________
OBSERVATIONS:
AM
PM
NIGHT
T / P / RR/ BP (TDS of stable) satis
□
□
□
Pain control ed with analgesia
□
□
□
Wound satis
□
□
□
Redivac: min. drainage (report bile to team)
□
□
□
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SURNAME: __________________________ NHI: ________________
FIRST NAMES: ____________________________________________
Clinical Pathway Elective
DATE OF BIRTH: _______/______/_______ SEX: ________________
Laparoscopic Cholecystectomy
Please attach patient label here
MEDICATIONS: AM
PM
NIGHT
Nausea / Vomiting control ed by antiemetics
□
□
□
Routine meds given
□
□
□
ACTIVITIES: Mobilised around room
□
□
□
FOF – LIFE as tolerated
□
□
□
IVF disc. If tolerating FOF
□
□
□
O2 disc if saturations normal
□
□
□
Nurse’s Name: ________________________________
Signature: ____________________________________
Notes: ______________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Name: _______________________________________
Signature: ____________________________________
DAY ONE (1st Post – op day)
Date:
OBSERVATIONS:
AM
PM
NIGHT
T / P / RR/ BP (TDS of stable) satis
□
□
□
Pain control ed with Paracetamol, NSAIDS
□
□
□
Pain control ed with Opiods
□
□
□
Wound is dry (use post – op opsite)
□
□
□
Time drain removed (on Drs instructions):
MEDICATIONS:
Nausea / Vomiting control ed by antiemetics
□
□
□
Routine medications given
□
□
□
ACTIVITIES: Mobilise
□
□
□
Shower
□
□
□
TEDS removed (if mobilising wel )
□
□
□
Lite diet tolerated
□
□
□
Time IVL removed:
Patient informed of 11:00 discharge time
□
□
□
Time O2 discontinued (if saturations normal): ________________________________________________________
Nurse’s Name: ________________________________
Signature: ____________________________________
Drs Rounds: □ Operation explained
Notes: ______________________________________________________________________________________
____________________________________________________________________________________________
Name: _______________________________________
Si
g
n
a t
u
r
e :
_
_
_
_
_
_
_
_
_
___________________________
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SURNAME: __________________________ NHI: ________________
FIRST NAMES: ____________________________________________
Clinical Pathway Elective
DATE OF BIRTH: _______/______/_______ SEX: ________________
Laparoscopic Cholecystectomy
Please attach patient label here
VARIANCE RECORD
Variance from clinical pathway? □ Yes □ NO
CRITERIA FOR VARIANCE
1. □ Length of stay > 2 days
Reason:
2. □ Operation variance
□ Open procedure
□ Bile duct exploration
3. □ Process issues
□ Incomplete documentation
□ Cancel ation
□ Incomplete preparation of patient
4. □ Other (state): ___________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
When documenting variance please state:
□ Variance as number (if variance includes 1. put reason in brackets e.g. 1 (pain)
□ Reason for variance
□ Date and time that variance occurred
□ What action has been taken
□ Sign and date entry
NOTES: _____________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Name: _______________________
S i
g
n
a t
u r
e :
_
_
_
_
_
_
_
_
_
___________
D
a t
e :
_
_
_
_
_
_
_
_
_
_______________
Discharge Checklist:
□ Wound Satis (opsite dressings)
□ Tolerating Diet
□ Instructions re GP fol ow – up given (wound check 7-10 days)
□ Instructions on when to return to work
□ Work CERT
□ Instructions given on driving
□ Transition Lounge transfer arranged
□ Lab form for fol ow–up tests in community if required
□ Prescription given
□ Discharge Summary given
□ Discharge Destination: ________________________
□ Transfer letter (if applicable e.g. RH, PH)
□ Transport organised
□ Valuables returned
□ Medications returned
□ Signed by nurse discharging patient: ____________________________ Date: ________________________
Please ensure variance documentation done
08/07
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SURNAME: __________________________ NHI: ________________
FIRST NAMES: ____________________________________________
Clinical Pathway Elective
DATE OF BIRTH: _______/______/_______ SEX: ________________
Laparoscopic Cholecystectomy
Please attach patient label here
Guidelines for Health Professionals
Clinical pathways (CPs) are designed to optimise, and standardise patient care. They serve as a guide for patient
care only. It must be stressed that clinical judgement is stil paramount and any abnormal findings should be
discussed with medical team.
When do you put a patient on this pathway?
Al adult patients who scheduled for elective laparoscopic cholecystectomy are suitable for ORDA process of
admission. If any co-morbidities exist please ask surgeon if pathway is appropriate.
What happens if surgery was postponed?
Just continue the existing pathway from time of postponement but change the dates. If the ORDA day page is
already fil ed in, use another ORDA page in it’s place. Variance related to cancel ation of the procedure should be
fil ed out on the variance page.
When should the patient come off the pathway?
When a patient experiences any of the variances itemised on the back page. At this point, care is managed as
before with a care plan and documentation put into clinical notes.
On the day of discharge, patient should be put back on the pathway to ensure al discharge outcomes are achieved.
What’s different about documentation in a pathway? The pathway has been designed to minimise the need for and reduce duplication of documentation. Tick
boxes are provided to note that expected outcomes are reached. Comments such as afebrile or tolerating diet
are not required. It
is important however that you sign and date the care you complete (
NB AM, PM, NIGHT
shift columns). The pathway is stil the legal document that records your care and therefore your accountability.
If there are no problems doctors should write “progress as per pathway” in NOTES section.
Every entry should be signed and dated.
What is a variance? Any outcome that should happen, but doesn’t
OR unexpectedly happens that shouldn’t. This can be anything
from bile duct injury to patient not being prepared for OR adequately
How should variance be documented? Variance should be documented in the NOTES section of the pathway and on the variance page.
Responsibility for documentation of white areas in pathway lies with nursing staff. Shaded areas are for
doctors. It is important that if variance occurs, a plan of action is decided upon, acted on, events documented,
and medical team notified
Does the pathway replace care plans? If the patient has NO variance-yes. However al variance must be managed using a plan of care. If this occurs
write “see care plan” next to documentation about variance so the rest of the team knows to refer to it.
Clinical Pathways are guidelines to care only. Clinical judgement should always be used to assess and
manage your patient safely.
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