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The World Health Organization (WHO) published the WHO Surgical Safety Checklist in 2008 in order to increase the safety of patients undergoing surgery. [1] The checklist serves to remind the surgical team of important items to be performed before and after the surgical procedure in order to reduce adverse events such as surgical site infections or retained instruments. [1]
The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...
IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery IPSG.5 Reduce the Risk of Health Care–Associated Infections IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls.
The ICD-10 Procedure Coding System (ICD-10-PCS) is a US system of medical classification used for procedural coding.The Centers for Medicare and Medicaid Services, the agency responsible for maintaining the inpatient procedure code set in the U.S., contracted with 3M Health Information Systems in 1995 to design and then develop a procedure classification system to replace Volume 3 of ICD-9-CM.
In 1991 the National VA Surgical Risk Study (NVASRS) began in 44 Veteran's Administration Medical Centers. By 31 December 1993, there was information for 500,000 non-cardiac surgical procedures. In 1994 NVASRS was expanded to all 128 HVA hospitals that performed the surgery.
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Preanesthetic assessment (also called preanesthesia evaluation, pre-anesthesia checkup (PAC) or simply preanesthesia) is a medical check-up and laboratory investigations done by an anesthesia provider or a registered nurse before an operation, to assess the patient's physical condition and any other medical problems or diseases the patient might have. [1]