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Chapter 8: Surgical Procedures

Preparing the Surgical Patient

In our previous section, we discussed the scheduling and admission process for patients in the hospital setting. Many patients in the hospital are admitted for surgical intervention; therefore, the HUC should also have a solid knowledge of the typical preparation required for surgical procedures.

 

Close-up of a physician (torso and arms only) in scrubs, white coat, and stethoscope making notes on a clipboard in a patient room.
HUCs prepare consent forms for patients based on the surgeon’s orders; the surgeon may also order pre-operative testing.

Consent Forms

In some clinical information systems, the consent form may be automatically created from the computerized physician order entry (CPOE) process; however, in other systems, the OR booking clerk or pre-surgical clinic HUC prepares consent forms for elective procedures, whereas the HUC in the ER or on the inpatient unit prepares consent forms for emergent procedures. It is important for clerical staff to have a good understanding of the abbreviations for common surgeries and how to spell the extended version correctly on a consent form. Regardless of how the surgeon notes the procedure on a Drs. order sheet or an OR booking sheet, the HUC should always write the full procedure name on the consent form that the patient signs, for risk management and legal purposes. For example, an order for a “lap. chole, poss. open chole” should be written out as “Laparoscopic cholecystectomy, possible open cholecystectomy”.

It may be part of the HUC role to print and review consent forms with patients prior to tests, especially in outpatient clinics. The HUC should always ensure that the patient has the opportunity to fully review the consent form and has any questions answered by appropriate staff. If a patient is unable to read the consent form due to language barriers, the HUC should contact an interpreter or family member to have them translate the document.

Common Surgical Consent Abbreviations

  • AAA:   abdominal aortic aneurysm
  • Appy:   appendectomy
  • BIL:   bilateral
  • BK:   below knee
  • BP:   bypass
  • Bx:   biopsy
  • Chole:   cholecystectomy
  • Cx:   cervix
  • D&C:   dilation and curettage
  • EUA:  examination under anaesthesia
  • Ext:   extraction
  • Fem-pop:   femoral-popliteal
  • FNA:   fine needle aspiration
  • I&D:   incision and drainage
  • IOL:   intraocular lens
  • Lap:   laparoscopic
  • LP:  lumbar puncture
  • Lt:  left
  • ORIF:  open reduction internal fixation
  • Poss:  possible
  • Rt:  right
  • Scope:  arthroscopy
  • STSG:  split-thickness skin graft
  • THA:  total hip arthroplasty
  • TNA:  total knee arthroplasty
  • TURBT:  transurethral resection bladder tumour
  • TURP:  transurethral resection prostate (RXFiles, 2020).

There are many, many more abbreviations that are used. The HUC will become familiar with the surgical procedures common to the unit that they are employed in, and familiar with the various ways these may be written out.

See the Appendix for a more comprehensive list of common short forms used in the hospital setting.

Routine Pre-Operative Testing

Surgeons usually note any pre-operative testing required for elective patients on the OR Booking form. If the patient attends the pre-surgical clinic, this testing is often completed there. If the patient does not attend a pre-op appointment, they may need to have testing done upon admission. The HUC in the pre-surgical clinic or on the unit that the patient is admitted to should carefully review the tests ordered on the OR booking sheet to ensure that they have been requisitioned.

In addition to tests specifically ordered by the surgeon, there may be additional standard investigations automatically required for the patient due to factors such as: age, diabetic status, type of surgery, BMI, or use of medications such as blood thinners, diuretics, or methadone.  The HUC may need to review standard testing guidelines for to ensure that all required tests are ordered pre-operatively. Every organization will have their own pre-op testing criteria for procedures which may include:

  • Blood Bank Guide
    • Outlines any required blood product to be on hold for surgical procedures listed. Blood bank requirements may range from a simple G&R (group and reserve) to a requirement to have a predetermined number of units of blood cross-matched and held for that patient’s surgical procedure.
  • Pre-Op Testing Guide
    • Outlines any required lab or ECG testing to be completed prior to surgical procedures based upon patient-specific criteria, such as age, diabetes, or taking certain types of medications such as blood thinners.

Practice Activity: Consent Forms

Convert the following abbreviated procedures to full wording for consent forms.

References

RX Files. (2020). Comprehensive RxFiles abbreviations list [PDF].

Attributions

Doctor Writing on a Medical Chart” by RDNE Stock project; used under the Pexels license.

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License

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Hospital Unit Administration Copyright © 2025 by Nancy Weatherhead is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, except where otherwise noted.