DPC Part B1 - ORPHF



B1Surgical Procedure1Particulars of the serviceScope of service FORMTEXT ?????Operating hours FORMTEXT ?????RecoveryNo of beds/ chairs: FORMTEXT ?????Sedation performed includes deep sedation or above?? Yes? No2Medical practitioner in-chargeIs the medical practitioner in-charge of the surgical service same as the Chief Medical Executive (CME)?? Yes? NoIf no, please complete the following information for the medical practitioner in-charge:Name in English FORMTEXT ?????(Surname) FORMTEXT ?????(Given names)Name in Chinese FORMTEXT ?????(Surname) FORMTEXT ?????(Given names)Qualifications FORMTEXT ?????Telephone number FORMTEXT ?????(Daytime) FORMTEXT ????? FORMTEXT (Emergency)E-mail address FORMTEXT ?????3Nurse-in-charge (if applicable)Name in English FORMTEXT ?????(Surname) FORMTEXT ?????(Given names)Name in Chinese FORMTEXT ?????(Surname) FORMTEXT ?????(Given names)Qualifications FORMTEXT ?????4StaffingNumber of staffNurseRN: FORMTEXT ?????EN: FORMTEXT ?????Clinic assistant FORMTEXT ?????Others (please specify): FORMTEXT ????? FORMTEXT ?????5Procedural sedationIs procedural sedation performed in the facility?? Yes (Please proceed to section?5.1)? No (Please proceed to section 6)5.1 Staffing for procedural sedationEvidence to substantiate complianceFor each procedure with sedation, in addition to the medical practitioner responsible for the procedure, there is:an appropriately trained staff in monitoring vital signs and procedural complications? Yes? NoDuty rostertechnical/ nursing assistance as required? Yes? NoDuty rosterCompetency requirements set out by Hong Kong Academy of Medicine (HKAM) for medical practitioners responsible for the sedation and staff assisting in sedation process are met? Yes? NoStaff qualification/ credentialing policy5.2Facilities and equipment for procedural sedationAll procedures are performed in a location equipped with:Evidence to substantiate compliancesource of oxygen and suitable devices for administering oxygen to spontaneously breathing patients? Yes? NoOxygen supplysource of oxygen with a suitable delivery system, a means of inflating the lungs, a supply of drugs for resuscitation, and a range of intravenous equipment and fluids for cardiopulmonary resuscitation? Yes? NoResuscitation equipment and drugsdrugs for the reversal of benzodiazepines and opioids? Yes? NoDrugsa tilting operating table, trolley or chair with ready access for induction and recovery of sedation? Yes? NoVenue for induction and recoverypulse oximeter and devices for the monitoring of vital signs? Yes? NoEquipmentan ECG and a defibrillator? Yes? NoEquipment 5.3Monitoring and recovery for procedural sedationEvidence to substantiate complianceAll patients are monitored continuously with pulse oximetry, which must give off visual and audible alarms when appropriate limits are transgressed? Yes? NoEquipmentThere is end-tidal carbon dioxide monitoring with capnography for patients where there is high risk of sudden unexpected loss of consciousness or when loss of consciousness has already occurred? Yes? NoEquipment There are regular recordings of pulse rate, oxygen saturation and blood pressure throughout the procedure in all patients? Yes? NoForm/ recordPatient is monitored for an appropriate duration after the procedure in an area adequately equipped and staffed for recovery care and monitoring of patients? Yes? NoForm/ record/ documentPatient discharge is authorized by the medical practitioner providing the sedation after adequate assessment, or by another medical practitioner with proper delegation and handover? Yes? NoForm/ record/ documentA set of standard discharge criteria is adopted to facilitate a consistent and reliable assessment and a safe discharge? Yes? No? NAForm/ document/ record6Critical or major equipment(e.g. monitoring and resuscitation equipment)Type of equipmentQuantitySchedule of maintenance as per the manufacturer’s recommendationDate of last serviced FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????7Policies and proceduresWritten policies and procedures on the following are in place:Evidence to substantiate compliancestaffing arrangements for surgical procedures and anaesthesia? Yes? NoDuty rosterinformed consent? Yes? NoConsent formchecking of consent forms before surgical procedures? Yes? NoForm/ recordpre-procedural assessment? Yes? NoForm/ recordpre-procedural instructions (e.g. fasting, medication) and care? Yes? NoForm/ noticeaccomplishment of pre-procedural preparation before surgical procedures? Yes? NoForm/ recordverification processes before surgical procedures, including time-out? Yes? NoForm/ recordcounting of items used during the procedures and what to do if items cannot be accounted for? Yes? NoForm/ recorddocumentation of procedures? Yes? NoForm/ recordpatient discharge and care after discharge:discharge criteria? Yes? NoForm/ recorddischarge instructions and advice? Yes? NoNoticearrangements for enquiries or assistance outside operating hours? Yes? NoNoticearrangement for post-procedural complications (e.g. arrangement for inpatient care)? Yes? NoDocumentinfection control? Yes? NoDocumentemergency transfer of patient to hospital? Yes? NoDocumentreview of appropriateness of patient care and monitoring of clinical performance and outcomes (e.g. complication, emergency transfer, unanticipated hospital admission)? Yes? NoDocument8Resuscitation and contingencyEvidence to substantiate complianceEmergency medications are stored in a designated and easily accessible area in the facility? Yes? NoSite environmentViability of emergency medications are regularly checked? Yes? NoDocumentFrequency:Every FORMTEXT ????? month(s)There are staff-to-staff communication systems for emergency in the operating/ procedure room and recovery area? Yes? NoDocumentDrills for emergency transfer? Yes? NoDrill/ recordFrequency:Every FORMTEXT ????? month(s) ................
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