{"text":"Acute Services Division \nSurgery & Anaesthetics \nGG&C Day Surgery\/23 hour C \nAdmission Checklist \nare Plan \nNa CLELLAND \n!_ Agnes \nDX Kilsyth \nDU \n08\/09\/1 955 \n39 Rennie Road \nGlasgow, Lanarkshire \nGe\u00e9sop __J \nPreoperative Checklist continued \nPre-operative checks Admission Check Reception Check N\/A Anaesthetic Check \nHearing aid(s) R O o0 vaB31r O 0O vaO (R O \u00a2 O na )ZI\u2019 \nHearing aid(s) removed \nIf removed state where stored: Insitu CJ Removed [ | Insite [J Removed [ | insitu (1 Removed [J \nC|D question asked Please see page 1 Please see page 1 \nAnswer to CJD question Checked [J Checked \nIf CJD question has not been asked Please see page 1 Please see page 1 \nthen ask the question E}\/ \n\u201c Have you ever been notified that you Checked [1 Checked \nare at an increased risk of CJD or vCID \nfor public health purposes?\u201d \nRSA screen results (if applicable) ) \nPasitive [] Negative (1 Comments if required: \nResults Pending (] nald \n- \nInhalers \/ Sprays with patient Yes ]j\/ Ne O wnaO Type: \nState Type : F tSh\/\\V\\-\"\u2018\\ C,\\\\ V\\\" SF WA~ \nAnti-embolic\/DVT Prophylaxis Ys O No O NA Type: \nState Type \nPaper Pants in situ W . Yes B\/ N O N \n. - \nVoided urine\/ Catheter in situ\/ Yes = No O wal Comment if required Comment if required \nUrostomy (circle) ; \nDate of Last Menstrual period See P1 Checked [1 \u00a2 See P1 Checked L] \nIs there any chance you are pregnant? See P1 Checked [ See P1 Checked[d \/| \nPregnancy test carried out See P1 Checked [ See P1 Checkecy\/ \nPregnancy test result ' \n~impon Removed Ys 0 No O wN\/A [T See Admission Check See Admissioff Check \nomments: Checked (] Checked \nLocal anaesthetic cream applied Yes O w~aALL\u2014 If \u201cYes\u201d time If \u201cYes\u201d time \napplied.....ovvcnemececrirenaans applied....cueeeiceeneiverenen. \n| \nSite(s) applied.....ccovvrvercenn Site(y) applied \nPre-Medication Given ves 0 n~a O~ Yes 01 n2a0d Yes O w~naO \n- \u2018 Z \nTrodlleoygjd checked for head down tilt | peg [ Trotey [0 Bed (1 Troley [ Bed 0 Trolley &~ \nan ceessories Operating Chair [ Operating Chair [ Operating Chair [ \nYes [0 No O Yes 0 No O Yes (1 No | \nAny relevant medical history or oth% \ninformation \nQo 63 fnle\u2014 Nt \nan OV \nFepiri \nQ&\\ V\u2018\u2014\\\\G\\\/\\\\ \nN AT~ \nO s\u20141eids \nBneoisqen \nM5 \n= \nPlease print and sign name once the \nchecklist is complete \nAdmission: . ; \nTime: \n\\az_\ufb01%\\{s\\\\oez- \nQA W hmay \nReception: N\/A O \nTime: \nAnaesthetic Assistant: \nTime ej 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