Patient Health Information Form Instructions

Please complete the Patient Health Information form. You may return the completed form in one of three ways:

  • Fax the completed form to 301-552-8895 prior to the day of surgery.
  • If you are coming to the hospital for any testing or educational classes prior to your date of surgery, bring your completed form with you.
  • Bring the completed form with you on your day of surgery.

If you have had surgery at Doctors Community Hospital within the last three months, you do not need to complete another form; however, we do need you to identify any changes that have occurred in your health status since your last visit.

Please remember to bring any required X-rays or mammograms with you on the day of your surgery.

Medication Record

On the Patient Health Information form, please list all medicines that you routinely or frequently take, including current prescriptions as well as over-the-counter and herbal medications. Please list the name of the drug, the dosage and how frequently you take the medication. This information helps your physician keep an accurate record of all your medications. Herbal and dietary supplements need to be stopped for two weeks before surgery. Supplements such as ginkgo, vitamin E, garlic, ginger and feverfew can interfere with coumadine (warfin). Also, Mega Men vitamins should be discontinued at least two weeks prior to surgery due to possible drug interaction risks.

Informed Consent

Informed consent is a communication between you and your physician/surgeon. When you are evaluated for your procedure, the physician will explain the procedure and have you sign a consent form authorizing or agreeing to undergo a specific procedure. Please feel free to ask your physician any questions you may have prior to signing the informed consent.

What To Expect

A week before your procedure, you will receive two calls from our staff. One call will be to register you for your procedure. The other call will be from a pre-anesthesia evaluation nurse, who will complete your pre-surgical anesthesia assessment. At that time, you will receive specific preparation instructions from our nurse who will review the Patient Information Form with you. Please be prepared to provide a current list of your medications and information about any recent physician and/or cardiologist visits.

Pre-Operative Testing

A pre-operative examination with additional tests may be necessary. If your pre-procedure tests are scheduled at Doctors Community Hospital, please report to the Outpatient Surgical Services registration desk located at the back of the hospital.

HOURS OF OPERATION

Monday through Friday – 6 a.m. – 5 p.m.
After Hours – Register in the Emergency Department

If you are required to go to an independent testing site, we will obtain your test results before your scheduled procedure. Please notify your physician when you have completed the test(s).

Please have all necessary tests completed no later than 30 days prior to surgery. Last minute test results could possibly result in a delay or cancellation of your procedure.

The Day Before Your Procedure

If you will be under general anesthesia, do not eat or drink anything after midnight prior to your procedure, unless your physician or anesthesiologist tells you otherwise.

  • Do not chew or eat gum, candy or mints after midnight.
  • If you are having local anesthesia, please follow your physician’s specific instructions.
  • Do not smoke or drink alcohol for at least 24 hours before your surgery. If you require assistance with abstaining, please advise your surgeon.
  • Confirm your transportation arrangements with a family member or friend. After your procedure, you will not be able to drive home or use public transportation on your own. If you are only having local anesthesia, this does not apply. If you do not have a ride home, your procedure may be canceled.
  • If your procedure requires admission (overnight stay), discharge time is 11:00 a.m. Please make sure your ride home knows to pick you up by 11:00 a.m. on the day you are to be discharged.
  • Shower or bathe with antibacterial soap before your procedure to minimize the chance of infection. Notify your physician immediately if you have developed a cold, sore throat, fever, rash or any other health problems. Your physician may wish to postpone the procedure.

Speak Up

Participate in all decisions about your treatment. You are the center of your healthcare team.

  • You and your doctor should agree on exactly what will be done during each step of your care.
  • Understand that more tests or medications may not always be better. Ask your doctor what a new test or medication is likely to achieve.
  • Don’t be afraid to seek a second opinion.
  • Know who will be taking care of you, how long the treatment will last and how you should feel.

(Information provided by The Joint Commission’s Speak Up Program.)

The Day Of Your Procedure

  • Arrival – Please plan to arrive at least two hours prior to your scheduled procedure time.
  • Transportation – Verify your pre-arranged transportation home. Confirm the time and place for pick-up.
  • Clothing and Make-up – Wear comfortable, loose-fitting clothing to the hospital. Do not wear make-up, nail polish or jewelry to the hospital.
  • Medical Guidelines – Unless otherwise directed, you should take your usual medications the day of surgery. Pills may be taken with a sip of water.
  • Tobacco – Do not smoke or chew tobacco the day of surgery.
  • Personal Items – Bring your insurance card, a complete list of medications currently being taken, X-rays and mammograms with you. Also, bring your eyeglass case, contact lens case and solution, hearing aids and dentures. To
  • Valuables – DO NOT BRING money, jewelry, watches, cellular phones or other valuables. The hospital does not replace or reimburse for such lost or missing items.
  • Cellular Phones – Please remember that the use of cellular phones is prohibited inside the hospital, as they cause interference with the electronic equipment.
  • Waiting Room – Family and friends are welcome to stay in the waiting room. While there, they will be informed when your surgery is complete and when you have been moved to the recovery room. They will be notified of your room number if you are admitted into the hospital.

Surgical Safety

Identification and Procedure Verification

We will verify your name and birth date, the correct site and side of your surgery, and the correct procedure we intend to perform. With you involved, awake and aware, this confirmation will take place:

  • When the procedure is scheduled
  • When you enter the facility
  • Before you enter the procedure room

Marking the Procedure Site

If necessary, the site of your procedure will be marked before you are taken to the procedure room. You will be awake and involved in the marking if possible.

Time Out

A time out will take place before your surgery. All members of your procedure team will confirm who you are, the procedure to be performed as well as the side and site of the procedure.

Anesthesia

Before surgery, you will meet with an anesthesiologist and your physician to determine what type of anesthesia is most appropriate for you and your procedure. The anesthesiologist will complete a brief physical examination and discuss the type of anesthesia to be administered. Types of anesthesia include general, sedation, epidural, nerve blocks or local.

Pain Management

Our healthcare team will monitor you closely during and after your procedure for pain. After your procedure, you will be asked to measure your pain on a scale from zero (0) to ten (10). Zero (0) is no pain, five (5) is moderate pain, and ten (10) is really severe pain—the worst imaginable.

Your physician will determine which pain medication is best for your type of pain and will prescribe the appropriate dosage.

Please keep the nurses informed if you continue to have pain so we can make you more comfortable.

The Day After Your Procedure

  • Follow the instructions on the discharge sheet as reviewed with you by the nurse.
  • Do exactly what your physician instructs you to do.
  • Call your physician if you have any questions.
  • If you had an outpatient procedure, you will receive a post-operative telephone call from a nurse within 24 hours of your procedure.

Financial Information

Surgical procedures at Doctors Community Hospital are covered by most major health insurance plans. However, you may be required to pay a portion of your bill. Our financial counselors are available at 301-552-8623 to answer any questions you may have.

In addition to a hospital bill, you will receive separate bills from your surgeon and other physicians (such as the anesthesiologist, pathologist, radiologist and/or cardiologist) who cared for you during your procedure.