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Patient identifiers refer to the inevitable components that are needed to commence the processes related to treatment of a patient. According to Cleveland Clinic’s policies and procedures, patients ought to be identified by two factors: date of birth / full name and medical record number. These identifiers would be used for accessing any details about the patient and identifying related information. The identifiers are recorded electronically in the clinic’s database system, written on patient’s wrist, and mentioned on paper charting systems. The identifiers help staff avoid confusing clinical information of different patients with one another.
Document Forms Required
Consent forms are required to be filled out for each patient before surgery. Consent forms are to be signed by the patient, surgeons, and anesthesia providers. Patients are informed of the necessary details and requirements as well as possible outcomes of the treatment.
Sources of Data Collection
Since patients with diverse histories and backgrounds come for treatment or surgery, it is essential to assess and record the medical history of every patient so that the staff could know clearly their needs and plan subsequent treatment effectively. Certain situations may arise during the treatment of patients wherein they do not approve some practices due to demographic, religious, or personal attitudes and preferences. The consent form signed by the patients after informing them of treatment requirements includes approval or disapproval of such practices that are likely to be carried out in their treatment (Sivanadarajah, El-Daly, Mamarelis, Sohail, & Bates, 2017).
Cleveland Clinic’s Universal Protocols
Protocols for clinics include the guidelines to be followed in providing treatment to patients, or investigating particular details and findings related to patients. The protocols adhered to by Cleveland Clinic are in accordance with the Joint Commission’s standards. The universal protocol helps clinic’s staff consider and treat the patient under appropriate protocol. This process entails various phases. First, patient assessment is carried out following specific procedures for adult and pediatric patients. Second, airway protocol is applied to identify patient’s category, distinguishing between adults and children. Third, circulation is assessed for adults or children using separate shock protocols. The restriction procedure for spinal motion is followed where it has been indicated. Fourth, the vital signs including heart rate, blood pressure, respirations, room air SpO2 help are taken into account. Finally, the patient is categorized as per the given criteria and placed in the appropriate group.
Alterations of Health Causing Risks
The patient’s ability to rehabilitate and recover can be impacted severely based on the co-morbidities of the patient. The surgeons need to clearly know the medical history of the patient. Any varied forms of acquired disease must also come into consideration. The clearance for a specific treatment or surgery should only be given if the patient is able to go through the suggested treatment. This preoperative clearance will reduce the complexities that could possibly arise during the course of treatment.
Handoff communication is carried out between a clinician or nurse and another clinician or nurse. For a surgery, a patient’s handoff is transferred from preoperative nurse to intraoperative nurse to postoperative nurse (Chitkara, Dials, Schuh, Thompson, Wagner, & White, 2017). The anesthesia provider and surgeon transfers handoff to the nurses and this information or guidelines help them manage providing care to the patients. This allows the nurses to carry on providing care to the patient on the desired level.
Recovery: Phase 1
In phase 1, the patient is kept in PACU (Post-Anesthesia Care Unit), and his or her vital signs (heart rate, blood pressure, respiration, etc.) are observed closely. Pain management and fluid administration also begins.
Recovery: Phase 2
The second phase of recovery occurs in the medical surgical unit where nurses provide intensive care to patients to help them cope with illness, prevent disease, and promote health.
Chitkara, H., Dials, K., Schuh, K., Thompson, N., Wagner, C., & White, M. (2017). A Protocol to Enhance Nurse-to-Nurse Communication during Patient Handoff.
Sivanadarajah, N., El-Daly, I., Mamarelis, G., Sohail, M. Z., & Bates, P. (2017). Informed consent and the readability of the written consent form. The Annals of The Royal College of Surgeons of England, 99(8), 645-649.
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