The Department of Health & Human Services has developed a standardised post-operative orders form to ensure that all hospital staff are aware of the specific clinical orders relating to a patient’s post-operative care and to minimise any risks of harm.
The Victorian Hospitals Post-Operative Orders Form provides a standard format for surgeons and anaesthetists to provide clear and detailed instructions to medical and nursing staff upon clinical handover of a patient after an operative procedure.
The orders form is part of a series of post-operative order principles developed by the Victorian Surgical Consultative Council (VSCC) and the Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM), to improve the care and safety of patients after all invasive procedures.
Using these principles, all hospital operating suites and day surgery units should ensure that:
- Post-operative orders are documented for all invasive procedures.
- Clear policies and guidelines exist to support the implementation of post-operative orders.
- Standard tools exist to support the implementation of these policies and guidelines.
- The Victorian Hospitals Post-Operative Orders Form is completed for all procedures to provide an overview of the full management plan until the next medical review.
- Medical staff writing orders should have: knowledge of the procedure, the expected post-operative course and of potential procedural complications; knowledge of the patient’s condition in relation to the intra-operative course, the patient’s pre-existing co-morbidities, and their risk factors for developing complications; and understanding of the environment (staffing and facilities) where the patient will be managed post-operatively.
- Communication of post-operative orders must be written and verbal, with sign-off by staff making the orders and receiving the orders in theatre, recovery and the ward area.
- Criteria for escalation of care need to be incorporated into the post-operative orders.
- Staff responsible for acting on post-operative orders are responsible for ensuring they receive written documentation of the orders, a verbal handover, and for clarifying instructions before accepting care of the patient and for escalating care when indicated.
- Post-operative orders need to include both post-anaesthetic and post-surgical orders. While anaesthetic orders specific to the recovery room may be written on the anaesthetic record, anaesthetic orders or instructions pertinent to the ward need to be recorded as part of the general post-operative orders.