CC-UC-01500 Hospital surgical procedure - Basic flow

Actors

• Patient
• Medical doctor (MD)/registered nurse (RN)/respiratory therapist (RT)
• Surgical team (may include but not be limited to anesthesiologist, surgeon, operating room nurse[s], porters, respiratory therapist, etc.)

Pre-conditions

• Patient has a pre-scheduled procedure.
• Patient is covered under provincial/territorial health care insurance.
• Procedure requires general anesthesia.

Step	Description	Data elements collected	Result
1	Member of the surgical team validates health concern described by patient confirms the scheduled surgical procedure and prepares the patient for the operating room.	Health Concern Health Concern(s) Health Concern Body Site Health Concern Severity Health Concern Evidence Health Concern Date of Onset Health Concern Date of Resolution Health Concern Date of Diagnosis Health Concern Clinical Status Health Concern Category Health Concern Verification Status Health Concern Reporting Source	The patient's health concern is validated, the scheduled surgical procedure is confirmed, the patient is prepared for the operating room, and the patient's medical record is updated in the hospital information system.
2	Patient is transferred to operating room and surgical team completes briefing checklist.	Not applicable	The patient is transferred to the operating room, the surgical team briefing is completed, and the patient's medical record is updated in the hospital information system. CC-UC-01401 Consent is not given.
3	MD/RN/RT performs induction and maintenance of general anesthesia to sedate the patient.	Medication Medication Dose Value Medication Dose Unit of Measure Prescribed Medication Dose Type Medication Ingredient Strength Value Medication Ingredient Strength Unit of Measure Medication Route of Administration Medication Timing Medication Dosage as Needed Flag Medication Duration Value Medication Duration Unit of Time Medication Total Quantity Value Medication Total Quantity Unit of Measure Medication Repeats Medication Usage Start Date and Time Prescribed Medication No Substitution Flag Medication End Date and Time Medication Usage Information Medication Statement Date and Time Medication Usage Status Medication Usage Status Reason Medication Incident Description Medication Reason	General anesthesia is induced and maintained, the patient is sedated for the surgical procedure, and the patient's medical record is updated.
4	Surgical team completes timeout checklist and performs procedure successfully.	Procedure Category Procedure Performed Procedure Status Procedure Status Reason Procedure Date and Time Procedure Reason Procedure Body Site Periprocedural Event Procedure Tolerance Procedure Tolerance Narrative Post-Procedure Instructions	The surgical timeout checklist is completed, the surgical procedure is successfully performed, and the patient's medical record is updated in the hospital information system. CC-UC-01403 Unexpected intraprocedural event.
5	Patient emerges from general anesthesia, is awakened and undergoes a medical stability assessment to confirm medical stability before transfer to the post-operative unit.	Not applicable	The patient is awakened, medically stable for transfer to the post-operative unit, and the patient's medical record is updated.
6	Patient is discharged with instructions for post-operative care and follow-up.	Not applicable	The patient is discharged with post-operative care instructions and follow-up. The patient's medical record is updated in the hospital information system.
7	Use case ends.	Not applicable	Not applicable

Post-conditions

• Surgical procedure is successfully completed.
• Patient is transferred to post-operative unit.
• Patient is discharged with post-operative care and follow-up.
• Patient's medical record is updated in the hospital information system.

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