Surgery also often called an “operation”, is an invasive process because an incision is made into the body to repair or remove or replace a part of body tissues or organs as the best treatment for his or her disorder.

As surgery always carries a high level of risk, the surgeon will assess each patient and weigh the surgical risk against the need for surgery.

In some cases, surgery must be done despite the high level of risk due to the presence of risk factors, for example the common instance of  patients presenting for surgery with a pre-existing physical disorder risk factor from diabetes mellitus, with slowed healing, increased incidence of infections, insulin imbalances, inability to regulate blood sugar levels.

When a person is brought in by ambulance and must receive immediate surgery, this emergency patient needs emergency surgery. The assessment process for an emergency patient is carried out in a shortened time frame and the surgery performed immediately to save the patient’s life. Examples are ectopic pregnancy with threat of rupture, severe internal hemorrhage, ruptured appendix, and angioplasty after a heart attack.

So in most normal circumstances, patients for which surgery is planned have a medical assessment and all required tests performed before the surgery. Assessment(s) provide information necessary to :

1. select the appropriate procedure and the optimal time identified from sequencing the assessments in the clinical care path on a timeline for the patient
2. perform procedures safely
3. interpret findings of patient monitoring

The selection of an appropriate invasive procedure considers information from the following sources used to develop and to support the planned invasive procedure by the responsible surgeon before the procedure is performed :

1. the initial medical and nursing assessment(s) on the patient’s history and physical status
2. available results that have been reported within a time frame to meet the patient needs (in this case the impending surgery) for all required tests, such as electrocardiogram (ECG), ordered laboratory tests, radiology and diagnostic imaging study

The surgical care planned for the patient is documented in the patient’s medical record, more so if the hospital is seeking or plans to continue maintaining accreditation status  dictated by standards from a hospital quality assurance agency like that of the Joint Commission International (JCI). The JCI standard on documentation by the surgeon prior to surgery is the  Standard ASC.7, which states that “Each patient’s surgical care is planned and documented based on the results of the assessment”, requires the surgeon to document the following prior to performing surgery :

1. procedure selected
2. a preoperative diagnosis in the Preoperative Note which is a progress note documented by the surgeon prior to surgery, which summarizes the patient’s condition – the name of the surgical procedure alone does not constitute a diagnosis (JCI 2011)

However I think documentation on the surgical care plan should also incorporate the following although they are not mentioned to meet JCI Standard ASC.7 :

1. emotional support provided to the patient and the family, especially to the patient who faces surgery as the patient may compare the previous experience with this one and can be particularly frightened if the patient has had any previous experience with surgery which was difficult or the patient facing surgery for the first time may be apprehensive about pain, about losing consciousness, fearful of cancer or of being disabled or worse still some others maybe afraid they will die
2. preparation of the patient physically for surgery for example a surgical preparation or “prep” is done by cleaning the skin with an anti-infective agent and may be shaved when an incision is to be made in the skin
3. that all legal matters, such as signing the surgical consent (informed consent), are carried out
4. routine preoperative care provided

JCI does not say where in the medical record the surgical care plan should be documented. From my experiences, these are often documented in the progress notes and are authenticated by the responsible surgeon.

In summary, If documentation is completed as above in the medical record of a patient prior to surgery, then the hospital seeking or planning to continue maintaining accrediation status from JCI,   will fully meet  JCI’s Standard ASC.7 and it’s four (4) measurable elements.

References :
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA