Nkwanta Surgical Outreach

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Nkwanta Surgical Outreach

Patient Screening Form

Outreach
Date
Unique ID
1

Registration

Patient identification

Unique ID
Date
Outreach event
Full Name
Surname, Other names
Age (years)
Sex
MaleFemale
Phone Number
Hospital Number
NHIS Number
Insurance status
NHIS – activeNHIS – expiredPrivate insuranceNo insurance
Home / Digital Address
e.g. NT-0001-2345
Major City
Nearest major city / town
Identifying structure of location
Nearest landmark
Occupation
Farmer / FisherTrader / Market vendorArtisan / Skilled workerCivil / Public servantStudentUnemployedOther (specify)
Level of Education
Education level
No formal educationPrimaryJunior High SchoolSenior High SchoolTertiary / UniversityVocational / TechnicalPost-graduate
2

Anthropometry

Measurements, vitals & labs

Weight (kg)
Height (cm)
BMI
Blood Pressure
Reading 1 — Systolic
Reading 1 — Diastolic
Reading 2 — Systolic
Reading 2 — Diastolic
Average BP
Interpretation
NormalElevatedStage 1 HypertensionStage 2 Hypertension
Other Vitals
Pulse (bpm)
SpO₂ (%)
RBS (mmol/L)
3

History / Triage

Complaint, medical history & labs

Chief complaint and duration
Medical History
History of Hypertension
YesNo
History of Diabetes (DM)
YesNo
Asthma
YesNo
Sickle cell
YesNo
Previous surgery
YesNo
Previous surgery details
What surgery, when
Allergies
YesNo
Allergy to what
Drugs, foods
How do you react to the allergy?
Wheals, itching, respiratory distress
Current medications
Social History
Smoking
YesNo
Alcohol
YesNo
Parity
e.g. P2+1
Review Labs
HB (g/dL)
WBC (×10⁹/L)
PLT (×10⁹/L)
Urea (mmol/L)
Creatinine (µmol/L)
Other lab — parameter
Result
Other lab — parameter
Result
Access to Care
Barriers to accessing surgical care (tick all that apply — ask the patient what prevented them from seeking surgical care earlier)
Cost of surgery / hospital feesDistance to surgical facilityLack of transportLack of awareness of the conditionFear of surgery / anaesthesiaCultural or traditional beliefsPrioritized other household responsibilitiesLack of health insuranceLong waiting times at hospitalsNo perceived worsening of symptomsAdvised to wait by traditional healerLack of support from familyPrevious bad experience with healthcareNo barriers — sought care promptlyOther
If other, specify
Would you have been able to afford the surgery outside of this outreach?
Yes, easilyYes, with difficultyNo, could not affordUnsure
How did you hear about this outreach programme?
Community health workerRadio announcementHealth facility referralFamily/FriendFlyer/posterChurch/mosque announcementSocial mediaOther
If other, please specify
4

Surgery

Surgical review

Surgical conditions
Thyroid mass / GoitreUterine fibroid(s)Inguinal herniaUmbilical herniaIncisional herniaFemoral herniaHaemorrhoidsLipomaSebaceous cystLymph node swellingBreast lump (benign)Other soft-tissue lumpOther (specify)
Other — specify
Thyroid function tests (required if thyroid mass / goitre)
T3
T4
TSH
Reason for surgery
In the patient's own words
Notes / findings
Location, size, characteristics
Assessment
Pre-op diagnosis
Fit for surgery
YesNo
Reason
5

Gynae

Gynaecological review

Fibroid
YesNo
Abnormal uterine bleeding
YesNo
Ovarian cyst
YesNo
Vulvovaginal mass
YesNo
Other
YesNo
Other — specify
Notes / findings
Assessment
Pre-op diagnosis
Fit for surgery
YesNo
Reason
6

Anesthesia

Pre-anesthetic assessment

Have you ever had any anesthesia?
YesNo
Will you accept blood transfusion?
YesNo
General Condition
State of hydration
GoodFairObesePuffiness
Psychological
CalmApprehensiveUnstable
Colour
CyanosisPallorJaundice
Febrile
YesNo
Respiratory System
Any cough
YesNo
Distress
YesNo
Catarrh
YesNo
Chest auscultation
ClearInaudibleWheezingCracklesRhonchi
Air entering — Adequate
YesNo
Air entering — Reduced
YesNo
Respiratory rate (cpm)
Cardiovascular System
Chest pain
YesNo
Fatigability
YesNo
Palpitation
YesNo
B/P (mmHg)
Pulse (bpm)
Heart sounds (HS)
Airway Assessment
Airway assessment
Mallampati class, mouth opening
Neck movement mobile
YesNo
Any stiffness
YesNo
Any denture
NoYes — permanentYes — removable
ASA Physical Status Classification
Anaesthetic risk
ASA I — Normal healthy patientASA II — Mild systemic diseaseASA III — Severe systemic diseaseASA IV — Life-threatening diseaseASA V — Moribund patient
Outcome
Anesthesia assessment
PassFail
Remarks
7

Booking / Review

Decision & comments

Booked for surgery
YesNo
Surgery date
If not booked
CounselReferConservative treatment
Comment
Comment
8

Theatre / Peri-op

Operative & post-operative record

Preop
Preop vitals
BP, pulse, SpO₂, temperature
FBS (fasting blood sugar)
Hydration
HydratedNot applicable
Signed consent form
YesNo
Intraop
Preop list
Pre-operative checklist / orders
Surgery date
EBL (estimated blood loss, mL)
Time started
Time ended
Surgeon name
Assistant name
Scrub nurse
Procedure (tick all that apply)
Total thyroidectomySubtotal thyroidectomyHemithyroidectomy / LobectomyMyomectomy (open)HysterectomyInguinal hernia repair (open — Lichtenstein)Inguinal hernia repair (open — Bassini)Umbilical hernia repairIncisional hernia repairFemoral hernia repairHaemorrhoidectomy (open)Rubber band ligationExcision of lipomaExcision of sebaceous cystExcision of breast lumpExcision biopsy of lymph nodeOther soft-tissue excisionOther (specify below)
If 'Other', specify procedure
Indication
Intraop findings
Final intraop diagnosis
Blood transfusion required intra-operatively?
YesNo
If yes — number of units
Sample taken for histopathology?
YesNo
Post op plan
Anesthesia
Name of anesthetist
Technique
General anesthesiaSpinalRegional blockLocal anesthesiaSedation
Airway
ETT / LMA / face mask
Anesthetic drugs and dosage
Other drugs used (with doses)
BP before knife on skin
BP before moved to recovery
Intraop anesthetic events
Notes
Recovery
Time in
Time out
Vitals on arrival
BP, pulse, SpO₂, temperature
Time of recovery from anesthesia
Vitals before transferring out
Other vitals / monitoring
Recovery findings
Fit for ward
YesNo
Post Op — daily reviews
Day 1 — date, vitals, notes
Day 2 — date, vitals, notes
Day 3 — date, vitals, notes
Pain assessment — score 0–10
Pain @ 1 h
Pain @ 4 h
Pain @ 8 h
Pain @ 12 h
Pain @ 24 h
Pain medications
Drug, dose, route, frequency
Post-operative complications (tick all that apply)
NoneWound infection / SSIWound dehiscenceHaematoma / SeromaBleeding requiring interventionRecurrent laryngeal nerve injuryHypocalcaemia (post-thyroidectomy)Urinary retentionDeep vein thrombosis (DVT)Pulmonary embolismPneumonia / Respiratory complicationAnaesthetic complicationReturn to theatreOther
9

Discharge

Outcome, medications & patient feedback

Discharge status
Discharged wellDeath in hospitalDischarged against medical advice (DAMA)Referred to higher centreOther
If 'Other', specify
Discharge medications (tick all that apply)
AnalgesicsAntibioticsAntihypertensivesHaematinicsThyroid replacement therapyWound care instructionsOther
If 'Other', specify medication
Follow-up instructions
Patient satisfaction (1 = Strongly Disagree … 5 = Strongly Agree)
I was treated with respect and dignity throughout the outreach.
12345
The healthcare team explained my condition and procedure clearly.
12345
I was satisfied with the quality of surgical care I received.
12345
My pain was well-managed during my hospital stay.
12345
The outreach venue and facilities were adequate and clean.
12345
I would recommend this outreach programme to others.
12345
The outreach programme was easy to access from my community.
12345
I feel my health has improved since the procedure.
12345