UW HEALTH CLINICAL POLICY 1
Policy Title: Discharge of Surgical Outpatients through Outpatient Surgery Center,
First Day Surgery, and TAC Perioperative Services
Policy Number: 2.3.4
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: March 1, 2016
To facilitate evaluation of patient’s status for discharge home.
II. POLICY ELEMENTS
Prior to patient’s discharge, it will be required that:
A. Patients will have a discharge order in the electronic medical record (EMR) by Anesthesiology. (Refer to
Order Set: Anesthesiology – Adult – Recovery/PACU)
B. When “criteria” are used to discharge patients, the Phase II Discharge Criteria section will be utilized. Upon
discharge, a score of ≥ 16 should be present. No single criteria should have a major deficiency. A
physician’s order is needed for a score of < 16 at time of discharge.
C. Outpatients should be received in the Phase II recovery area to allow adequate time for full patient recovery,
assessment, and post-op teaching.
D. Patients must arrange for a responsible person (age 16 or older) to accompany them home. Patients will not
be allowed to drive themselves home, and are required to have adult supervision through the first night.
Unaccompanied general public transportation is not acceptable.
E. Written and verbal post-op instructions will be given to the patient and responsible party. The After Visit
Summary (AVS) with the written instructions will include patient demographics, allergies, appointments
scheduled for the next 120 days or to be scheduled by the patient (if applicable), discharge
instructions/orders, and the patient’s current discharge medication list. The patient will receive an
Anesthesia instruction sheet along with emergency numbers to contact if a problem arises.
A. Patients will have a discharge order written by an anesthesiologist. (Refer to Order Set: Anesthesiology –
Adult – Recovery/PACU)
B. Discharge instructions are verbally reviewed with the patient and responsible party. The AVS is sent, along
with the Anesthesia instructions and emergency contact numbers.
i. Order sets, along with the post op instructions, are tailored to the surgical intervention performed.
Documentation of written instructions (AVS) is reviewed and sent with the patient. In addition,
discharge instructions are reviewed, and provided to the designated responsible party. The name
of the responsible party and a statement of understanding of discharge instructions are
documented in the Additional Instructions section of the AVS.
C. Order sets are tailored for the surgical intervention performed. Specific post op patient teaching tools –
Health Facts For You (HFFY) are utilized and the HFFY number is documented in the AVS. Often times the
post op teaching is initiated in the pre op workup, and Learning Center. Staff can review, reinforce, and build
upon this in preparation for discharge home. The teaching is documented in the EMR and is reflected in the
D. The postoperative care planning is individualized, and is a multidisciplinary effort involving representatives
from Anesthesia, Surgery and Nursing.
Author: Director, Surgical Services Department
Senior Management Sponsor: SVP, Patient Care Services and CNO
Reviewers: Medical Director, Outpatient Surgery Center; Surgical Services Supervisor, Ambulatory Surgery;
Assistant Director, Pre/Postoperative Care
Approval committees: Surgical Services Policy and Procedure Committee; UW Health Clinical Policy
UW Health Clinical Policy Committee Approval: February 15, 2016
UW HEALTH CLINICAL POLICY 2
Policy Title: Discharge of Surgical Outpatients through Outpatient Surgery Center/First Day Surgery Center
Policy Number: 2.3.4
UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.
Peter Newcomer, MD
UW Health Chief Medical Officer
J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee
Anesthesiology – Adult – Recovery/PACU Order Set
Appendix: Discharge Criteria After UW Health Ambulatory Anesthesia Care
VII. REVIEW DETAILS
Next Revision Due: March 1, 2019
Formerly Known as: Surgical Services departmental policy #2.09