Surgeon to sign at bottom of page.
The reason you need to have surgery is: _______________________
The name of the surgery is: _____________________
I have done this same surgery on about ____ patients in the past 3 years.
There is a (circle) poor, fair, good, excellent chance the surgery will resolve your problems.
The surgery will not fix the following things:
Expect the following short term effects of surgery:
Expect the following long term effects of surgery:
Diagram of surgery:
Although I believe the proposed surgery is best, the next best treatment would be the following:
I have accurately told you the most frequent complications of surgery but I do not expect any complications. Complications are not random events and they always have a cause. I will do my best to prevent complications and errors by:
- Following evidence based guidelines
- Using a pre-op check list
- Working as a team with everyone in the operating room
- Following recommendations from the pharmacy and quality improvement departments
- Being honest about errors and informing you of them immediately
- Being available for any problems that arise
- Calling specialists to help with difficult problems
When you are fully awake after surgery I will personally go over the findings of the surgery. If there are any outstanding test results when you leave the hospital we will call you later to let you know those results.
Our hospital has surgical hospitalists who are available 24 hours a day. Whenever you, your family or the nurses feel immediate attention is needed — just call the following number for their help ____________.
If you need to be in a critical care unit of the hospital I will ask a critical care specialist to consult and coordinate treatment. I fully support the team approach to severe illness which includes a multidisciplinary rounding program.
Before you leave the hospital we will review all your medications and make sure you know the correct ones to take after you get home. I will FAX (or send by computer) a full report about your surgery and medications to your primary care doctor on the day of discharge. And, I will send a copy to you.
We will write down all instructions when you go home but feel free to call me at this number if you have questions or problems: __________________
My nurse will call you the day after discharge to make sure everything is going well. Your follow up appointment will be just a few days later.
I expect to be away from the hospital during this time: _______________
My associate ______________ will fill in for me during that time, but rest assured, I will take the time to personally go over your situation with my associate so they can fill my role without difficulty.
Signed Dr. __________________________ Date __________________