The Perioperative Service


• Appropriately comprehensive information about the patient’s health status should be documented prior to the planned procedure.

• The patient should be assessed to be in their best reasonably achievable health status prior to a planned procedure.

• Information about the patient should be readily available to any health professional caring for the patient to enable appropriate clinical decision-making.

• The patient should have an appropriate understanding of the rationale for the planned procedure, the expected benefits, the alternative treatments available, and the risks of having the procedure and associated care.

• The plan of care for the procedure should be determined by a process that integrates requirements arising from procedure-specific issues, patient health issues, the patient’s personal preferences, and the requirements of the system or hospital.

• The plan of care should be documented either as in accordance with predetermined ‘routine management’ for that procedure, or where relevant or at variance from usual process, as separate aspects of planned care.

• Persons caring for the patient should know of the requisite observations that must be performed to identify possible adverse outcomes, and be able to respond appropriately to ‘unexpected’ outcomes.

• At all times there should be a clearly understood hierarchy of responsibility for decision-making regarding any aspect of care for the patient.