{"text":"Acute Services Division \nSurgery & Anaesthetics e, =t 53 \nCreat:lr \u00e9\u2018.lla;gow CLELLAND \nGG&C Day Surgery\/23 hour Care Plan and Clyde | Agnes 08\/09\/1955 \n. \" 39 Rennie Road . \nKilsyth v\/ \nAdmission Checklist \nNHS \nR \nGlasgow, Lanarkshire \nG65 9PQ \nWi \u2014 \n\u2014_\u2014 \nHospital : &Dbh\\lj\\- \nConsultant :M\u2018JD md\ufb02}l\u2018 \nDate : C\u2018la\\l 8 ] \nProposed Operation:- |5V \nPatient Questionnaire Completed? \nMpS fuston W 1o \n20 Pigy Risto \nO \n0 \nNo \nPre-Op assessment Completed? \n\\5je) 13 . \no \nYes \nNo n \nEscort Details (responsil:rleAdult)Namei,tu\u2018x\u2018awo ol * lfQI\\zob @ cave. a.h&\"i%m\u201de Number: \nConfirm \u201cNext of Kin\u201d on pre-assessment Name\ufb02mm { G \nJ \nCoeye ) \nTelephone No: (Y Q34 - 3219 '\\. \n\/ \nInterpreter Required? If \u201cYES\u201d confirmation of booking Yes O No LV \nDuration of booking (if Known)......eevvvmmmeecciiiieececcen \narer required to stay with patient? Ys [ No IQ\/ \nDate of LMP? pateMNO.... 10N HAS . \u2018 \nAre you, or could you be pregnant? Yes O - No V \nIf \u201cYes\u201d pregnancy test must be performed \nPregnancy test results +VE -VE N \u201dQ \nGroup and save results checked Yes a No ( N\/\ufb02 \nDate done.....coeerireinneiserneiiinnn \n| Anti D required ves 0O N O NJA \nIs the patient on Anti-Coag therapy? W}}gg Yes \ufb02 No [0 \nif \u201cYes\u201d state type....cocoeveiiiiransns o ;\ufb01e_\\'w \nAre INR results available within last 24hrs? m@\"w lo | Yes O \nIf \u201cNo\u201d INR taken date ............ time........... - RV ReSUMt...uriceareererinns No O \nIs the patient diabetic If \"Yes, N O \nBM on admission resul \u20185%@. N bD [ o \nUrinalysis done Results.........ccieeireeeeiiinnaniae No 6][\/\\\u2018) \nCJD single question asked ' oo O Comment if\\r:auired \nIf at risk theatre notified \n-.nswer to CJD single question At Increased Risk u B \nNot at increased Risk * TOuieraeerirerinnes \nIf CJD question-has not been asked then ask the question \u201d flave you ever \nbeen notified that you are at an increased risk of CJD or v\u20ac|D for public \nhealth purposes?\u201d \nYes, | have been-notified \nI have not been notified \nCommment if required \nAlert Sticker (i required) Yes [ NA \nDoes the patient have any pressure area issues? If \u2018Yes\u2019: Yes O No o \nAT@R...coriveisestacnersessanannaae \n15SU@+\/= SCOT..cvseererreacnrrrnennanrens \nTissue Viability contacted Yes *N\/A \nOther Information- Document any other relevant information e.g. needle \nphobia , request for female practitioner \u2018Getting to know you\u2019 infarmation, Ml st \nFit Farm required Yes | No m\/ \nBaseline Observations \n'Dl\\ba olon\\b \nGorbepentint o, nz \nIS coaioda. MenoNithede. 2oy 7 \nA \nfm \nc.C ?_O..,D \nX G 8mx @ 858 \nedans \ntws \nWiexovinrumd Soomy - \u2019 \nBP \nHR \nTemp \nStaff Initials \n5% \nPlease print & sign name when checklist completed \nName l\\Oatud&n\ufb02 e&ry \nTime : \nS &m \nGGCO121 C1 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