Peri-Operative Care Plans

Pre-Operative Care Plan Template

Key Objectives

Provide patients with a digital care plan providing them with pre-operative information and their assessment for day surgery.

Outcome measures

Equip patients with the information and assessment that's completed before day surgery admissions for surgery.

Current Baselines

Patients don't currently have access to the pre-operative assessment completed by the team.

Example HTML code for Pre op care plan template

a {word-wrap: break-word;}

.form-group {width: 100%; !important}

.cp_whiteBox {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; border-radius: 10px; border: 3px solid #014151;}

.cp_separator {height: 3px; background-color: #898989; margin-top: 5px; margin-bottom: 5px;}

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<label class="cp_label" for="cp_preferName">Preferred Name:</label>

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<label class="cp_label" for="cp_escortName">Named Escort:</label>

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<label class="cp_label" for="cp_escortNameTel">Telephone No:</label>

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<label class="cp_label" for="cp_escortNameNOKtel">Telephone No:</label>

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<label class="cp_label" for="cp_dataSharePerson">Name of person patient agrees information can be shared with:</label>

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<label class="cp_label" for="cp_GPaddress">Address:</label>

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<label class="cp_label" for="cp_GPtel">Telephone No:</label>

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<label class="cp_label" for="cp_consultant">Consultant:</label>

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<label class="cp_label" for="cp_consultantDept">Department:</label>

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<label class="cp_label" for="cp_proposedProcedure">Proposed Procedure: </label>

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<label class="cp_label" for="cp_surgeryDate">Date to attend Day Surgery Unit:</label>

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<label class="cp_label" for="cp_preadmissionDate">Pre-admission contact date: </label>

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<label class="cp_label" for="cp_namedNurse">Named Nurse:</label>

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<label class="cp_label" for="cp_primaryNurse">Primary Nurse:</label>

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<label class="cp_label" for="cp_preassessmentDate">Date of Pre-assessment:</label>

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<label class="cp_label" for="cp_preassessmentTime">Time of Pre-assessment:</label>

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<label class="cp_label" for="cp_nurseComments">Pre-assessment nurse's comments:</label>

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<label class="cp_label" for="cp_nurseSignature">Signature:</label>

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<label class="cp_label" for="cp_nurseGrade">Grade:</label>

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<p>Special needs discussed at Pre-assessment:</p>

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<label class="cp_label" for="cp_specialNeedsDiscussed1">Large Print</label>

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<label class="cp_label" for="cp_specialNeedsDiscussed2">Audio Tape</label>

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<label class="cp_label" for="cp_specialNeedsDiscussed3">Other Language</label>

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<label class="cp_label" for="cp_specialNeedsDiscussed4">Special Diet</label>

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<label class="cp_label" for="cp_specialNeedsDiscussed5">Spiritual Needs</label>

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<label class="cp_label" for="cp_specialNeedsDiscussed6">Mixed Sex Environment</label>

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<label class="cp_label" for="cp_specialNeedsDiscussed7">Complaints Procedure</label>

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<h2>PATIENT TO COMPLETE:</h2>

<h2>ASSESSMENT FOR ADULT CARE IN THE DAY SURGERY UNIT</h2>

<p>1. have someone to take you home?</p>

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<p>2. provide your own transport?</p>

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<p>3. have a telephone at home?</p>

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<p>4. have easy access to a lavatory?</p>

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<p>5. have someone to look after you for 24 hours?</p>

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<h3>Have you ever suffered from:-</h3>

<p>6. chest pain?</p>

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<p>7. breathlessness?</p>

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<p>8. chest disease (ie. asthma, bronchitis)?</p>

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<p>9. high blood pressure?</p>

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<p>10. a heart attack or heart murmur?</p>

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<p>11. fainting easily?</p>

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<p>12. fits (epilepsy)?</p>

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<p>13.jaundice (yellowness)?</p>

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<p>14.indigestion or heartburn?</p>

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<p>15.kidney or bladder trouble?</p>

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<p>16. anaemia or other blood problems?</p>

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<p>17. excessive bleeding or bruising?</p>

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<p>18. arthritis?</p>

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<p>19. muscle disease or progressive weakness?</p>

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<p>20. diabetes or pass water very often?</p>

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<p>21. an allergy to a general or local anaesthetic?</p>

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<p>22. a serious illness?</p>

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<p>23. an allergy to medicines, Elastoplast etc.?</p>

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<p>24. take tablets, medicines, patches etc.? Please specify</p>

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<p>25. smoke?</p>

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<p>26. drink over 1 1/2 pints of beer or 3 shorts per day?</p>

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<p>27. if a woman, do you take the pill or are you pregnant?</p>

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<p>28. need to inform the staff of anything else?</p>

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<label class="cp_label" for="cp_haveYou_29">29. Please list previous operations:</label>

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<label class="cp_label" for="cp_haveYou_30">30. Please list any complications you have had after surgery or anaesthetics:</label>

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<label class="cp_label" for="cp_haveYou_31">31. When was your last anaesthetic:-</label>

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<p>32. Has any member of the family had problems with anaesthetics?</p>

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<p>32. Do you have any of the following</p>

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<label class="cp_label" for="cp_haveYou_32_1">dentures</label>

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<label class="cp_label" for="cp_haveYou_32_2">crowned/ veneered teeth</label>

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<label class="cp_label" for="cp_haveYou_32_3">pacemaker</label>

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<label class="cp_label" for="cp_haveYou_34">34. How long will it take to travel home?:</label>

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<label class="cp_label" for="cp_haveYouPatientSig">Patient's signature</label>

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<label class="cp_label" for="cp_haveYouAssessor">Assessor:</label>

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<label class="cp_label" for="cp_haveYouAnaesthetist">Anaesthetist:</label>

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<h2>For Professional use Only: PREOPERATIVE PHASE</h2>

<label class="cp_label" for="cp_daySurgeryAdmittedDate">Admitted to Day Surgery Unit on:</label>

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<label class="cp_label" for="cp_namedNurse2">Named Nurse:</label>

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<label class="cp_label" for="cp_nurseGrade2">Grade:</label>

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<label class="cp_label" for="cp_nbmTime">Nil by mouth from time:</label>

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<label class="cp_label" for="cp_menstrualDate">Date of last menstrual period</label>

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<p>Pain score is discussed and agreed acceptable level is recorded on post operative sheet:</p>

<label class="cp_label" for="cp_changesIDd">Identified changes since assessment in Outpatient Clinic:</label>

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<label class="cp_label" for="cp_preopSig">Signature</label>

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<p>Do you understand that after your operation and anaesthetic YOU SHOULD NOT:</p>

<ol>

<li>A) drive a motor car or any vehicle for 24 hours</li>

<li>B) operate machines or home appliances for 24 hours</li>

<li>C) drink alcohol for 24 hours</li>

<li>D) make important decisions for 24 hours</li>

<li>E) be left on your own without a responsible person for 24 hours</li>

</ol>

<label class="cp_label" for="cp_assessDate">Assessment data rechecked by:</label>

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<label class="cp_label" for="cp_recentInfections">Any recent infections:</label>

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<p>Information confirmed by patient</p>

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<label class="cp_label" for="cp_confirmSig">Signature:</label>

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<label class="cp_label" for="cp_confirmSigGrade">Grade:</label>

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<label class="cp_label" for="cp_actionTaken">Action taken:</label>

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<h2>FOR PROFESSIONAL USE:</h2>

<label class="cp_label" for="cp_namedNurse3">Named Nurse:</label>

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<p>Complete the relevant preoperative safety checks using the following checklist:-</p>

<p>Consent form corresponds to patients understanding</p>

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<p>Consent form is signed</p>

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<p>Identity band is correct and sited securely</p>

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<p>Operation site has been marked and shaved if necessary</p>

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<p>Make up is removed</p>

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<p>Jewellery is removed or taped</p>

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<p>Dentures, bridges, crowns, hairpiece removed/left in situ</p>

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<p>Property box is sealed and accompanies the patient</p>

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<p>The patient understands the sequence of the days events and is given the information leaflets related to their operation</p>

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<label class="cp_label" for="cp_uses_1">Contact lens</label>

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<label class="cp_label" for="cp_uses_2">hearing aid</label>

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<label class="cp_label" for="cp_uses_4">prosthesis</label>

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<label class="cp_label" for="cp_usesSigned">Signed:</label>

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<label class="cp_label" for="cp_usesAction">If no to any of the above questions, action taken:</label>

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<label class="cp_label" for="cp_usesSigned2">Signed:</label>

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<label class="cp_label" for="cp_usesCounterSigned">Counter signature:</label>

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<h2>Operation Summary</h2>

<label class="cp_label" for="cp_operation">Operation:</label>

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<label class="cp_label" for="cp_surgeon">Surgeon(s):</label>

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<label class="cp_label" for="cp_Anaesthetist">Anaesthetist(s):</label>

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<p>Anaesth:</p>

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<label class="cp_label" for="cp_AnaesthetistsAssistant">Anaesthetists Assistant:</label>

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<label class="cp_label" for="cp_ScrubPerson">Scrub Person:</label>

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<label class="cp_label" for="cp_CirculatingPerson">Circulating Person:</label>

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<p>Sutures Used:</p>

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<label class="form-check-label" for="cp_suturesAbsorb"> Absorbable</label>

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<label class="form-check-label" for="cp_suturesNon"> non-absorbable</label>

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<label class="cp_label" for="cp_dressing">Dressing:</label>

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<label class="cp_label" for="cp_painControl">Local Anaesthetic for pain control:</label>

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<label class="cp_label" for="cp_sutureRemovalDate">Date for suture removal:</label>

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<label class="cp_label" for="cp_outPatient">Out-patients appointment:</label>

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<label class="cp_label" for="cp_specimenSent">Specimen sent:</label>

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<label class="cp_label" for="cp_signed">Signed:</label>

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<label class="cp_label" for="cp_additionalComments">Additional information/comments:</label>

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<label class="cp_label" for="cp_additionalCommentsSignature">Signature:</label>

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<h2>POST OPERATIVE PHASE</h2>

<label class="cp_label" for="cp_recoveryArrival">Arrival in recovery at</label>

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<input type="text" name="cp_recoveryArrival" id="cp_recoveryArrival" class="form-control" style="width: 100%;"/> hours

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<p>Airway present:</p>

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<label class="form-check-label" for="cp_airwayGuedel"> Guedel</label>

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<p>Oxygen:</p>

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<label class="cp_label" for="cp_patientAwake">Patient awake at:</label>

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<label class="cp_label" for="cp_signed3">Signed:</label>

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<label class="cp_label" for="cp_grade3">Grade:</label>

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<label class="cp_label" for="cp_PainScore">Pain Score</label>

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<option value="--">Select</option>

<option value="2 - moderate pain">2 - moderate pain</option>

<option value="3 - severe pain">3 - severe pain</option>

<option value="4 - unbearable pain">4 - unbearable pain</option>

</select>

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<label class="cp_label" for="cp_NauseaVomitinaScore">Nausea/vomitina score</label>

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<option value="--">Select</option>

<option value="1 - no nausea or vomiting">1 - no nausea or vomiting</option>

<option value="2 - mild nausea">2 - mild nausea</option>

<option value="3 - moderate nausea">3 - moderate nausea</option>

<option value="4 - vomited">4 - vomited</option>

<option value="5 - vomited more than twice">5 - vomited more than twice</option>

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<p>Dressing/wound checked:</p>

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<label class="form-check-label" for="cp_dressingCheckedclean"> clean</label>

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<label class="form-check-label" for="cp_dressingCheckedintact"> intact</label>

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<p>Pressure Areas Checked:</p>

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<label class="cp_label" for="cp_pressureshoulders">shoulders</label>

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<label class="cp_label" for="cp_pressureelbows">elbows</label>

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<label class="cp_label" for="cp_pressuresacrum">sacrum</label>

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<label class="cp_label" for="cp_pressureheels">heels</label>

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<label class="cp_label" for="cp_pressureankles">ankles</label>

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<label class="cp_label" for="cp_recoveryActions">Actions undertaken as a result of problems arising during recovery phase:</label>

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<label class="cp_label" for="cp_signed4">Signed:</label>

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<h2>PRE DISCHARGE ASSESSMENT</h2>

<p>1. TPR and BP are within patient's preoperative limits</p>

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<p>2. Wound/dressing checked</p>

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<p>3. Does patient feel faint when mobilising?</p>

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<p>4. Has patient drunk at least one cup of fluid?</p>

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<p>5. Patient has passed urine</p>

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<label class="cp_label" for="cp_preDischarge_6">6. If urology patient, was urine?</label>

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<option value="--">Select</option>

<option value="clear">clear</option>

<option value="clots">clots</option>

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<p>7. Does pain score exceed agreed limits?</p>

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<p>8. Does nausea/vomiting score exceed level 2?</p>

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<p>9. The IV Cannula has been removed and V.I.P. Score recorded?</p>

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<p>10. The ECG sticker has been removed</p>

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<label class="cp_label" for="cp_actionTaken2">Action taken following identified problem:</label>

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<label class="cp_label" for="cp_actionTakenSig">Signature:</label>

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<h2>Requirements before discharge</h2>

<p>1. Patient understands relevance of the received analgesia/medication</p>

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<p>2. Patient has received and understands relevant information leaflets</p>

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<label class="cp_label" for="cp_dischargeReq_2Specify">Please specify:</label>

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<p>3. Patient has received a copy of discharge letter</p>

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<p>4. Time/date of follow-up appointment has been given</p>

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<p>5. Patient has been given relveant 24 hour hospital contact numbers</p>

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<p>6. The escort arrived to take the patient home</p>

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<p>7. Patient feels adequately prepared for discharge</p>

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<p>8. Discharge confirmed with medical staff/approved designated staff</p>

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<label class="cp_label" for="cp_actionTaken3">If no to any of the above questions - action taken:</label>

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<label class="cp_label" for="cp_signed5">Signature:</label>

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<label class="cp_label" for="cp_sigApprovedStaff">Signature of approved designated staff:</label>

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<label class="cp_label" for="cp_dischargeAt">Discharged from unit at:</label>

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<label class="cp_label" for="cp_signed6">Signature:</label>

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<label class="cp_label" for="cp_patientSig">Patient Signature:</label>

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Health Questionnaire Care Plan Template

Key Objectives

Provide patients with a digital health questionnaire care plan, assessing them for surgery.

Outcome measures

Equip patients with information and reduce clinical appointments

Current Baselines

All health questionnaires are on paper and sometimes forgotten by patients if sent prior to surgery or not shared with patients at all.

Example HTML code for Health questionnaire care plan template

a {word-wrap: break-word;}

.form-group {width: 100%; !important}

.cp_whiteBox {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; border-radius: 10px; border: 3px solid #014151;}

.cp_separator {height: 3px; background-color: #898989; margin-top: 5px; margin-bottom: 5px;}

</style>

<h2>Health Questionnaire - Assessing you for admission</h2>

<p>This questionnaire will provide us with an overall picture of your current state of health and will take around 30 minutes to complete. It's important that you provide us with detailed and honest information about your health and lifestyle choices.</p> <div class="row" style="margin-top: 15px;">

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<label class="cp_label" for="cp_escortNameNOKtel">Next of Kin Telephone No:</label>

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<label class="cp_label" for="cp_GPaddress">Address:</label>

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<label class="cp_label" for="cp_GPtel">Telephone No:</label>

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<label class="cp_label" for="cp_StateName">If you are completing this Health Care Questionnaire on behalf of a patient, please can you state your name and relationship to the patient:</label>

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<label class="cp_label" for="cp_dataStateProcedure">Please state what procedure/surgery you are attending the Hospital for?</label>

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<h2>PATIENT TO COMPLETE:</h2>

<p>Please confirm you have read and understand the Admission Information located in the <a href="/library/manageLibrary.action" target="_blank">Library</a> that contains all the relevant information you should need before, during and after your stay in hospital.</p>

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<p>Are you double vaccinated against COVID 19? (Double vaccinated is defined as receiving 2 doses of a COVID-19 vaccine and does not include any booster vaccinations.)</p>

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<p>Will you need an interpreter available on the day of your admission?</p>

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<p>Do you have any Mental Capacity issues that would mean you require a carer to escort you on the day of your admission?</p>

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<p>Will you have a responsible/capable adult at home to look after you for the first 24 hours following your operation/procedure?</p>

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</input>

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<p>Will you have access to a telephone for the first 24 hours following your operation/ procedure?</p>

</div>

<div>

</input>

</div>

</input>

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<p>Will you be able to provide your own transport WITH a responsible/capable adult escorting you if discharged within 24 hours following your operation?</p>

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<div>

</input>

</div>

</input>

</div>

<p>Have you had any previous surgery/procedures?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<label class="cp_label" for="cp_procedures">If yes please list the surgery/procedure and date.</label>

</div>

<p>Do you have any medical conditions e.g Diabetes, Asthma, COPD, Hypothyroid?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<label class="cp_label" for="cp_medicalCondition">If yes please list your medical condition:</label>

</div>

<p>Do you have a specific allergy to any of the following? Latex, Nickel, any metal, Gentamicin, eggs, nuts, anaesthetic medications, Iodine or CT contrast.</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have any allergies other than those listed above?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<label class="cp_label" for="cp_allergiesList">If yes please list your allergies here:</label>

</div>

<p>Do you have speech/vocal problems or needs?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Are you fully independent with mobility, and able to dress and undress yourself?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Have you ever had a blood transfusion?</p>

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<div>

</input>

</div>

</input>

</div>

<p>If yes, did you have any problems because of the blood transfusion?</p>

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<div>

</input>

</div>

</input>

</div>

<p>If you have had a blood transfusion, was it within the last 90 days?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Have you ever suffered with chest pain and/ or diagnosed with angina?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<label class="cp_label" for="cp_chestPain">If yes, please state when:</label>

</div>

</div>

<p>Have you ever been diagnosed with heart failure?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Have you ever been referred to a heart specialist?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<label class="cp_label" for="cp_specialistHospital">If yes, Please state the specialist/hospital you were referred to and when:</label>

</div>

<p>Have you ever had a heart attack?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have heart stents in place?</p>

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<div>

</input>

</div>

</input>

</div>

<p>Have you ever been diagnosed with a heart murmur or heart valve problems?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Have you ever suffered with a very fast, slow or irregular heartbeat, or have you been diagnosed with AF (Atrial Fibrilation)?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have high blood pressure, high cholesterol, or are you prescribed blood pressure medications?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you suffer from dizziness or fainting?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have a pacemaker or internal defibrillator in place?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<label class="cp_label" for="cp_24_hospital">If yes, in which hospital was it inserted and when?</label>

</div>

<p>Have you ever been diagnosed with any aneurysm (a diagnosed bulge or ballooning of blood vessels)?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<label class="cp_label" for="cp_26_Hospital">If yes, in which hospital was it diagnosed and when?</label>

</div>

<p>Have you ever been diagnosed with Peripheral Vascular Disease or any other blood circulation disorders?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Have you ever had a stroke/mini stroke or TIA?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<label class="cp_label" for="cp_28_when">If yes, please state when:</label>

</div>

<p>Do you suffer from any lung disease or other breathing problems such as asthma, bronchitis, COPD or TB?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you suffer with or are undergoing investigations into sleep apnoea?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you use a CPAP machine?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Are you breathless at rest or on minimal movement?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Can you climb one flight of stairs without breathlessness or chestpain?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Can you walk up to 100 yards (or 100 meters) without breathlessness or chestpain?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>If you lie down without a pillow do you become breathless and/or experience acid reflux?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you use a nebulizer or oxygen at home?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Within the last 6 weeks, have you suffered or are you currently suffering with a chest infection, cough, cold, or flu or are you producing phlegm?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you smoke, or have you ever smoked?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have any restrictions moving your neck or opening your mouth?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have any problems with your airway or had surgery on your airway that may cause intubation problems?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Have you or any of your family ever had a reaction to or complication with a general or local anaesthetic?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have dentures or crowned or veneered teeth?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have any loose, damaged or chipped teeth?

</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Have you suffered with nausea and or vomiting immediately after a procedure/ surgery?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have fits e.g Epilepsy?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have any neurological problems (e.g. Multiple Sclerosis, Parkinsons, Muscular Dystrophy, Motor Neurone Disease, Huntington's Disease)?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have any mental health conditions i.e. psychiatric disorders, depression, anxiety, self-harm?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Have you ever suffered with any liver problems e.g. Hepatitis?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Are you visibly yellow, or have been informed by a health professional that you have jaundice?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you suffer with Indigestion or heartburn problems, or have a hiatus hernia or suffer from acid reflux?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have swallowing problems?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Have you been diagnosed with grade 3 or 4 Renal Failure, or you receive Renal Dialysis?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have anaemia or other blood conditions e.g. sickle-cell, thalasaemia?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Have you been diagnosed with an immune-suppressing condition e.g HIV ?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you suffer with excessive bleeding or bruising, or suffer from any clotting disorders e.g Haemophilia, Von Willibrand's disease or factor deficiencies?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you take blood thinning medication?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have arthritis for which you take prescribed medication?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have any muscle disease, or any hereditary muscle disease e.g Myasthenia Gravis?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have diabetes, or are you currently undergoing investigation for diabetes?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you suffer from any thyroid problems?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you take any prescription medication that has NOT been prescribed by your GP?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<label class="cp_label" for="cp_nonPrescribedMeds">If yes, please list:</label>

</div>

<p>Do you take any over the counter medication/herbal remedies?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<label class="cp_label" for="cp_q64_herbalList">If yes, please list:</label>

</div>

<p>Do you take any recreational drugs e.g. Cocaine, Heroin, Cannabis?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you drink more than 20 units of alcohol a week? One unit is equal to a half a pint of lager/beer, one 125ml glass of wine or one 25ml measure of spirit</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Are you or could you be pregnant?</p>

</div>

<div>

</input>

</div>

</input>

</div>

</input>

</div>

<p>Are you taking the contraceptive pill?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Do you have a contraceptive device or contraceptive implant in place?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Are you taking hormone replacement medication e.g. HRT?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>If you are an ORTHOPAEDIC patient only, do you have any skin breaks, sores or cuts, including fungal nail infection?</p>

</div>

<div>

</input>

</div>

</input>

</div>

</input>

</div>

<p>If you are a NEUROSURGERY patient only, are you pain free?</p>

</div>

<div>

</input>

</div>

</input>

</div>

</input>

</div>

<p>Have you been diagnosed with Lymphoedema?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Have you been diagnosed as a carrier of Clostridium Dificile?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Have you ever been notified that you are at increased risk of CJD or vCJD for public health purposes?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>In the last 12 months, have you been an inpatient in a hospital within another Trust or abroad?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Have you been informed by a Health Professional as being positive for CPE or CPO? (Carbapenamase Producing Enterobacteriaceae, or Carbapenamase Producing Organisms)</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Have you been informed by a Health Professional as being colonised with or infected by MRSA? (Meticillin Resistant Staphylococcus Aureus)</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Is there anything not already asked that you think may be relevant to your health or your planned surgery?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<label class="cp_label" for="cp_q78_details">If yes, please give details:</label>

</div>

<p>Do you still want to go ahead with your planned surgery?</p>

</div>

<div>

</input>

</div>

</input>

</div>

<p>Thank you for completing this questionnaire, once you are happy all questions have been completed please use this button to go to the bottom of the plan and press save </p>

<p><a href="#fileUploadForm_save" class="btn arrow btn-primary" title="Goto the Save button" alt="Click here to go to the save button" style="margin-top:15px; margin-bottom:15px;">Goto the Save button</a></p>

</div>

<h2>For Clinical Use Only:</h2>

<label class="cp_label" for="cp_profAmendments">Care plan evaluation</label>

</div>

<label class="cp_label" for="cp_patientGeneralApperance">Patients general appearance:</label>

</div>

</div>

</div>

<label class="cp_label" for="cp_pulse">Pulse (RPM)</label>

</div>

<div>

<label class="form-check-label" for="cp_pulseType1"> *Regular</label>

</input>

</div>

<label class="form-check-label" for="cp_pulseType2"> *Irregular</label>

</input>

</div>

</div>

<label class="cp_label" for="cp_Temp">Temp (degrees C)</label>

</div>

</div>

<label class="cp_label" for="cp_sa02">Oxygen Saturations (%)</label>

</div>

</div>

<label class="cp_label" for="cp_height">Height (m/ cm)</label>

</div>

</div>

<label class="cp_label" for="cp_weight">Weight (kg)</label>

</div>

</div>

</div>

</div>

<label class="cp_label" for="cp_Urinalysis">Urinalysis</label>

</div>

</div>

</div>

<label class="cp_label" for="cp_pregnancyTest">Pregnancy Test Result</label>

</div>

</div>

<label class="cp_label" for="cp_peakFlow">Peak Flow (if indicated)</label>

</div>

</div>

<label class="cp_label" for="cp_bm">BM (if Indicated)</label>

</div>

</div>

Further information

Enhance recovery care plan template: post-operative kidney translate care plan to be completed by the patient and team for 10 days post-op
Consent care plan template: to be used as informed consent before a patients appointment for minor procedures and/or operations
Minor procedures care plan templates: collect information from the patient before appointment to reduce clinic time and to support patient empowerment
Orthopaedic prehabilitation plan template: a tool for the remote management of patients before their surgery
ACL reconstruction proforma care plan template: enhance recovery care plan for patients in hospital and post-discharge