Standard operating procedure

Admission & Pre-Assessment Procedure

How [Organisation Name] books, pre-assesses and admits patients for a planned treatment or procedure, confirms their fitness and suitability for care in an independent setting, and prepares them safely for the day of treatment

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What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Procedure
  • 6. Documentation and records
  • 7. Related documents
  • 8. Review and version control
  • 9. Disclaimer

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 9 (Person-centred care), Regulation 11 (Need for consent) and Regulation 12 (Safe care and treatment)
  • Care Quality Commission (CQC) single assessment framework
  • General Medical Council, Decision making and consent (2020)
  • Royal College of Anaesthetists, Guidelines for the Provision of Anaesthesia Services (GPAS): Pre-operative Assessment and Preparation (current edition)
  • National Institute for Health and Care Excellence, Routine preoperative tests for elective surgery, NICE guideline NG45 (2016)
  • National Institute for Health and Care Excellence, Perioperative care in adults, NICE guideline NG180 (2020)
  • Mental Capacity Act 2005 and its Code of Practice
  • Data Protection Act 2018 and the UK General Data Protection Regulation (UK GDPR)

Who it applies to

All clinicians, anaesthetists and sedationists, registered nurses and operating department practitioners, healthcare assistants, pre-assessment and admissions staff, reception and booking coordinators, and the registered manager or [Insert Job Title] at [Organisation Name] involved in booking, pre-assessing or admitting patients for planned treatment

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Anaesthetist
A doctor who specialises in giving anaesthesia and keeping a patient safe and pain-free during a procedure.
Anaphylaxis
A severe, life-threatening allergic reaction needing immediate emergency treatment.
Anticoagulant
A medicine that thins the blood and reduces clotting, which may need to be adjusted before a procedure.
Antiplatelet
A medicine such as aspirin or clopidogrel that stops blood platelets sticking together, which may need to be adjusted before a procedure.
ASA grade
A score from one to five (the American Society of Anesthesiologists classification) describing how fit a patient is for anaesthesia and surgery.
Baseline observations
The starting measurements of vital signs, such as blood pressure and pulse, used to compare against later readings.
Body mass index (BMI)
A measure of weight relative to height, used to gauge whether a person is underweight, healthy or overweight.
Capacity
Whether a person can understand and make a particular decision for themselves at the time it needs to be made.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Contemporaneous record
A note written at the time of, or as soon as possible after, the event it describes.
Cooling-off (reflection) period
A set period of time giving a patient the chance to think before agreeing to a procedure, without pressure.
Data Protection Act 2018
The UK law that governs how organisations collect, store and use people's personal information.
Difficult airway
A situation where it is harder than usual to keep a patient breathing or to insert a breathing tube during anaesthesia.
DNA (did not attend)
A booked appointment that the patient did not attend and did not cancel beforehand.
Elective procedure
A planned, non-emergency treatment that is scheduled in advance.
Episode of care
The whole planned course of treatment for a patient, from booking through to discharge.
Escort
A responsible adult who takes the patient home and, where needed, stays with them after sedation or anaesthesia.
Fasting
Going without food and, in some cases, drink for a set time before sedation or anaesthesia, to reduce risk.
Fundamental standards
The minimum standards of safety and quality below which care must never fall.
General anaesthesia
Medication that puts a patient fully to sleep so they feel nothing during a procedure.
General Medical Council (GMC)
The body that registers doctors and sets the standards they must follow in the UK.
General practitioner (GP)
A family doctor who provides general medical care in the community.
Guidelines for the Provision of Anaesthesia Services (GPAS)
Standards published by the Royal College of Anaesthetists for how anaesthesia services should be organised and delivered.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The law setting out the fundamental standards that providers of regulated health and care must meet.
Independent setting
A private clinic, hospital or service that operates without the on-site backup of a large acute general hospital.
Indication
The clinical reason that makes a particular treatment or procedure appropriate for a patient.
Informed consent
Agreement to treatment given freely after the risks, benefits and alternatives have been clearly explained.
Intensive care unit
A hospital ward providing close monitoring and life support for the most seriously ill patients.
Mental Capacity Act 2005
The law that protects and supports people who may be unable to make particular decisions for themselves.
National Institute for Health and Care Excellence (NICE)
The national body that produces evidence-based guidance on treatments and care.
Near miss
An event that could have caused harm but did not, by chance or because it was caught in time.
NG45 (Routine preoperative tests for elective surgery)
National guidance on which tests should, or should not, be done routinely before planned surgery.
NG180 (Perioperative care in adults)
National guidance on the care of adults before, during and after surgery.
Obstructive sleep apnoea
A condition where breathing repeatedly stops and starts during sleep, which can raise the risk of anaesthesia.
Operating department practitioner
A registered professional who supports patients and the clinical team before, during and after operations.
Optimisation
Improving a patient's health or controlling a condition before a procedure so it can be done more safely.
Oxygen saturation
A measure of how much oxygen the blood is carrying, usually read from a clip on the finger.
Perioperative
Relating to the whole period around an operation, including before, during and after it.
Pre-assessment
A structured check before treatment to confirm the patient is fit for the procedure and that the setting is suitable.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Risk assessment
A structured check identifying what could cause harm and what is being done to prevent it.
Royal College of Anaesthetists
The professional body that sets standards and training for anaesthetists in the UK.
Safeguarding
Protecting people's health, wellbeing and rights and keeping them safe from abuse, harm or neglect.
Sedation
Medication that relaxes a patient and reduces awareness during a procedure without putting them fully to sleep.
Single assessment framework
The structure the regulator uses to judge a service, built around quality statements and five key questions (safe, effective, caring, responsive, well-led).
Standard Operating Procedure (SOP)
A written, step-by-step instruction setting out how a particular task is to be carried out consistently and safely.
Surgical safety checklist
A standard list of checks completed by the team before, during and after an operation to prevent avoidable harm.
UK General Data Protection Regulation (UK GDPR)
The UK's main data-protection law governing how personal information is collected and used.

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