D.

Surgical Patient Care

1. Perioperative Patient Care is a surgical service that evaluate, monitor and manage pre,
intra and post-operative of the patients, and performed on all patients that undergo Surgery.
2. The patient that undergo surgery at Sanglah General Hospital has done surgery based on
the information from an assessment. The assessment tool is using IAP method
(Information, Analyze, Planning). The result from the assessment that used to plan the
surgery, including the diagnosis and treatment, were recorded by Doctor in Charge on the
medical record before the surgery were done. The assessment that have been done by the
resident of surgery, were supervised and verified by the Doctor In charge as its level of
competences.
3. The patient that admitted from Emergency room or the outpatient from polyclinic, were
assessed to get working diagnosis to determine the kind of surgery will be done for patients.
It is called Pre-Surgical Assessment. If during the period of care, the patient was
reassessed, The Pre-Surgical Assessment could be recorded on the Integrated Patient
Follow-Up Notes. The Pre-Surgical Assessment record all the patient problems, including
medical, physical, psychological, and socio-economic problems, and also the discharge
planning for the patient.
4. The following provision for patient that will undergo implantation surgery, such as:
a. Implant is a medical devices that fully or partially installed inside the human body, or
from the hole of the body for more than or equal to 30 days, or medical devices that
used to replace the certain body surfaces for more than or equal to 30 days.
b. Selection of the Implant based on the evidence base medicine and current government
regulation.
c. Every patient that will be a implant receiver, should be marked on the location of
operation based on the site marking procedures.
d. The needs of Qualification and training of Guest Staff during the Implant-Installation
Procedure, such as : certificate that related to field of knowledge, certificate of the
implant installation course, work licenses related to installed implant.
e. All of the implant that installed should be guaranteed for its sterility based on the factory
sterile indicator as well as from Central Sterilization Department, Sanglah General
Hospital Denpasar.
f. The report regarding unexpected event related to implant installation, in accordance
with the report of the patient safety incidents pathway.
g. The report of the malfunctioned implant based on the factory regulation standard.
 h. Doctor in charge should educate, inform and give special instruction regarding the
implant to Every patient that have been installed with implant.
i. All the implant that installed should be recorded on the implant usage form.
5. The patient and their family, or the decision makers, should get adequate information to
make them fully understand and participate on making a decision for patient care and giving
acceptance (informed consent) on the medical care processes. Information and education
should be include :
a. The risk of procedure /operation
b. The benefits of the procedure /operation
c. The potential complication that can be happened
d. Alternative surgical or non-surgical procedure that available to treat the patient.
6. Before the patient discharge from the operating room or from the recovery room to ward,
Doctor In charge or the Resident based on the level of competences, should write down
the surgery report. The surgery report, should contained this information, such as post-
operative diagnosis, name of the surgeon and their assistant, name of the procedure were
done, the details of the findings, is there any complication or not, tissue/specimen sample
for further examination, amount of blood loss and transfusion, serial number of the installed
implant, complete with date and sign from the Doctor In charge.
7. Post-operative care recorded on the medical record by the Doctor in charge,
anesthesiologist, nurses, or other professional that take care the patient to fulfill the
needs of patient on post-operative phase. Post-operative care plan based on the
assessment of needs, patient conditions and the type of surgery. Plan of care
contain all of the patient needs, include from the other unit such as medical
rehabilitation division and physical therapy, assessment method, follow-up
treatment. The post-operative service plan was documented on the medical record
24 hours after surgery.
8. Perioperative Nursing care in operating Room includes the nursing care from before, during
and after the surgery, were recorded on the patient medical record on perioperative nursing
care Form. Assessment, diagnosis of nursing, and plan of care of nursing on every step
perioperative nursing, were documented oleh surgical nurses. For the continuity of
perioperative nursing care in the operating room, postoperative nursing care planning is
listed in an integrated patient follow-up notes to be operated with nurses who care for post-
operative patients in the ward or intensive care room.
 9. The surgical procedures that are able to be served in operating Room Sanglah General
Hospital, Denpasar, include :
a. Cardiovascular-Thoracic Surgery Division
b. Neuro Surgery Division
c. Pediatric Surgery Division
d. Orthopaedic and traumatology division
e. Ophthalmologic division
f. ENT division
g. Oncologic surgery division
h. Urology division
i. Digestive surgery Division
j. Plastic Surgery and Reconstruction Division
k. Emergency Trauma and Acute Care Surgery
l. Vascular Surgery Division
m. Obstetrics and Gynecology division
n. Dental and Oral surgery Division
o. Kidney transplantation surgery
10. Service Quality of Surgery in Sanglah general Hospital, Denpasar is set by Hospital and
coordinated under the responsibility of the Head of the Central Operating Theatre.
11. Determination of Quality Measurement and Incidence Report in Surgery care is in
accordance with Quality improvement and Patient Safety Policy in Sanglah General
Hospital Denpasar.