Elective Surgery Programme Implementation Support Guide
Elective Surgery Programme Implementation Support Guide
Elective Surgery Programme Implementation Support Guide
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APPENDIX 5 - SAMPLE PRE-ADMISSION ASSESSMENT FORM<br />
(For completion by pre-admission assessment nurse)<br />
Date of Assessment ………………………………….<br />
Weight:<br />
_______________ Kgs<br />
Height: (spinal anaesthetics only):<br />
Blood Pressure:<br />
Pulse:(/min)<br />
Peak Flow (if relevant): Temp:<br />
Urinalysis:<br />
LMP: N/A<br />
Gravidex Sent Today: Yes No<br />
Glucometer (if relevant)<br />
SPO²:<br />
Smoker: Yes No<br />
Per /day:<br />
Referral to smoking Cessation<br />
Yes No<br />
Alcohol Intake _______ approx per week<br />
Dentures / Crowns / Loose Teeth / Own<br />
Top Bottom<br />
57 Model of Care for <strong>Elective</strong> <strong>Surgery</strong>