AMBULATORY SURGICAL CLINIC
1. PURPOSE
To provide outpatient procedures this includes same-day surgical care, as well as
diagnostic and preventative procedures.
2. SCOPE
The following members of the healthcare staff of Malabon Hospital and Medical Center
(MHMC) are covered by this policy:
Surgeon
Anesthesiologist
Internal Medicine (CP Clearance)
OR Nurses- 3 Manpower
Nursing Assistant
Pharmacist
Medical Record Staff
3. RESPONSIBILITY
To focused on providing surgical care without the need for the patient to stay in the hospital
overnight.
4. POLICY
4.Receiving Patient for Ambulatory Surgical Care
4.1 The patient will arrive at the minor OR complex to undergo the planned/scheduled
surgery.
4.1.1Ensure the clinic's referral order is available and bears the surgeon's signature, name
and license number (Please refer to Admission Policy)
4.1.2 Please take note of the minor OR schedule below.
8 AM to 5 PM Monday- Saturday, On-call on Sundays
Maximum 8 patients per day, with each procedure lasting no longer than an
hour.
4.2 Identify patients name, Medical Record Number (MRN) and procedure to be done.
4.3 Medical history as appropriate, including chronic problems, medications, and allergies
done by the Resident on Duty Doctor.
4.4 Taking up Vital Signs including Blood Pressure, Pulse rate, Temperature, Respiratory rate
and Oxygen saturation and Pain and document the assessment.
4.5 Diagnostic and therapeutic procedures, tests and results with the practitioners’ notation
to indicate review of those results done by the doctor.
4.6 Consent for operation must be obtained and signed by the patient, guardian for minor
patient (Please refer to Consent Policy and Procedure).
4.7 Assist the patient in putting on the hospital gown in the patient dressing room patient
accessories including jewelries, dentures and other things brought by the patient must be surrendered
to the relatives.
4.8 After checking everything, begin the procedure (Refer to Operating/Delivery Room Policy
Manual).
4.9 Post-operative care should be provided (Refer to Operating/Delivery Room Policy
Manual) and to keep the patient comfortable and safe (Refer to Fall Policy).
5. Preparing for discharge patient from ambulatory surgery care
5.1 Receives Doctor’s Order Sheet
5.1.1 Verifies order for discharge
5.1.2 Checks for specific instructions (medicines, diet treatment and return visits)
5.1.3 All prescriptions of take home medication must be done by the AP instead of
just signing the prescription pad.
5.2 Prepares patient for discharge
5.2.1 Informs other referral doctors of the discharge order
5.2.2 Carries out the specific instructions
5.2.3 Verifies and ensures that the following are attended prior to discharge clearance.
5.2.4 Discontinued & excess medicines, medical/surgical supplies, if any,
have been returned to pharmacy and CSR.
5.2.5 No order is pending at the nursing unit.
5.2.6 Floor stocks used by the patient have been charged /replaced.
5.2.7 Submit PF form to Billing office. The Nurses station shall forward to the Billing office
the names of the Attending Physicians and all other doctors to whom the patient is referred to,
including Surgeons and Anesthesiologist. Billing Clerk will contact all doctor’s concerned for their
professional fees.
5.2.8 Notify Billing office
5.2.9 Reviews the instructions concerning follow up care with the patient and relatives.
5.2.10 As soon as the patient’s bill is prepared, instruct relative to settle their accounts.
5.2.11 Receives from patient’s relative the discharge slip issued by the cashier. Check that
the clearance is duly signed by the cashier.
5.2.12 Counter checks the admission checklist for the completeness of charges used.
5.2.13 Follows up the accomplished Patient Evaluation Form, if any.
5.2.14 Assists the patient to dress and pack patient’s personal belongings.
6. Discharges patient from ambulatory surgical care
6.1 Places the patient on a wheelchair. Escorts patient from the room to the hospital lobby
and assists him in getting into his vehicle
6.2 A copy of discharge slip is given to the security guard.
7.Documents the discharge procedure and completes the chart
7.1 Records the following
7.1.1 Nurse’s notes should contain the following:
Condition of the patient upon discharge
Persons who accompanies the patient
Time the patient was discharged physically from the OR complex
7.1.2 Date and time of discharge to be noted in the Patient’s Data Sheet
Complete data of patient
All unused forms shall be removed from the chart
Enters patient name in the Discharge Logbook
Keeps the completed chart in a locked cabinet. Endorses all completed chart
to Medical Records properly.
