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Physician Offices Norfolk NE

Scheduling Form

  • Must be faxed same day as case is scheduled
  • Must be complete
  • Surgery officially scheduled and consent based on how the procedure is written on this form – please confirm with surgeon to avoid errors in preparation or on the day of surgery
  • Do not send patients over to facility for pre-registration type activities
  • Office may inform the patient as to what time they are tentatively scheduled but remind patient that this is subject to change. Fountain Point Surgery Center will give the arrival time during the pre-op call

Surgeon’s office should instruct patient when/if the patient should discontinue any medications that affect the procedure (NSAIDS, blood thinners, etc.). Fountain Point Surgery Center will instruct patients regarding all other medication to hold or take on the day of surgery.

H&P’s may be completed up to 30 days prior to surgical date. Please schedule these appointments so that all information can be RECEIVED by Fountain Point Surgery Center of Norfolk at least 5 days prior to the surgical date. Also, please send the H&P, lab reports, etc. as soon as they are complete rather than holding them for any reason. The sooner the Fountain Point Surgery Center receives this information, the better, so we can review their histories and try to prevent last minute delays or cancellations.

Please complete the blanks on the front of the Fountain Point Surgery Center Patient Brochure and send this with the patient at the time of scheduling. If the procedure is scheduled without the patient being physically present, please send the completed brochure via mail to them.

Fountain Point Surgery Center Patient Selection Criteria

Physical status classification of the American Society of Anesthesiologists is:

  • ASA 1- A normal healthy patient
  • ASA 2- A patient with a mild systemic disease
  • ASA 3- A patient with a severe disease that limits activity but is not incapacitating. (For additional information on ASA class refer to policy 8.3)

Only patients who are classified as I, II, III are candidates for outpatient surgery, Outpatient surgery is now routinely performed on many American Society of Anesthesiologist (ASA) class III patients who are stable medically, as well as on ASA classes I and II patients. Recent studies have documented the safety of this practice. Admissions and complications correlate with type of procedure, duration of surgery, use of general anesthesia, and patient age, rather than ASA classification.

Patients inappropriate for outpatient surgery:

  1. Adult
    1. Patients expected to have major blood loss when undergoing major surgery or have a diagnosis of hemophilia, or any significant bleeding disorder.
    2. Patients who require intracranial or cardiac intervention.
    3. Patients with history (or family history) of MH (malignant hyperthermia).
    4. ASA classes III and IV who require complex or extended, monitoring or postoperative treatment.
    5. Morbidly obese patients with significant respiratory tract disease.
    6. Patients with a BMI of 48 or greater with multiple coexisting cardiac or pulmonary problems that are poorly controlled and scheduled for general/MAC anesthesia (i.e. hypertension, angina, asthma, smoking, sleep apnea, etc.).
    7. Patients that are scheduled by the surgeon for nurse monitored anesthesia that have a BMI greater than 48, will be MAC cases, if approved by anesthesia.
    8. Patients with a need for complex pain management.
    9. Patients who require invasive lines.
    10. Patients requiring new tracheostomy or who is ventilator dependent.
    11. Patients that are known to require transfer to a hospital facility or will be required to stay in the facility longer than 23 hours.
    12. Patients with significant fever, wheezing, nasal congestion, and cough as symptoms of a recent upper respiratory tract or sinus infection.
    13. Any other factor or associated medical condition deemed by anesthesia to preclude the procedure being done at an ASC.
  2. Pediatric

    All pediatric patients (age 14 and under) must meet the same criteria as adults. In addition to the above criteria the following pediatric patients are not appropriate for surgery at the facility:

    1. Formerly premature infants of less than 65 weeks post-conceptual age, even if healthy, have an increased risk of post-anesthetic apnea. Regardless of type of anesthesia, these infants should be admitted for a day of post-operative apnea monitoring, and thus are not eligible to be done as an ASC patient.
    2. Infants with respiratory disease such as severe bronchopulmonary dysplasia, apnea, or bronchospasm, unstable or incompletely treated asthma.
    3. Pediatric patients less than three (3) years of age for tonsillectomy, adenoidectomy or dental procedures, and less than 9 months for ear tube surgical procedure.
    4. Infants with cardiovascular disease such as congestive heart failure or hemodynamically significant congenital heart anomalies.
    5. Pediatric patients with multiple congenital anomalies; i.e. respiratory, cardiac and airway abnormalities.
    6. Children with fever, cough, sore throat, coryza, or other signs of recent onset of worsening upper respiratory tract infection.
    7. Obese children-the child presenting for elective surgical procedures that are obese have a greater prevalence of preexisting comorbid medical conditions, including an increased incidence of perioperative adverse respiratory events compared with normal-weight children. An obese child will be individually assessed by the anesthesiologist for identification and awareness of risk factors for perioperative complications which would hinder the anesthetic management of those children in an ambulatory surgery center.
  3. Asthma Policy:

    In general, the following types of asthmatics are not eligible for routine scheduling at the Center:

    1. Any asthmatic that has been treated in a center or a center emergency room within the last two weeks.
    2. Any asthmatic who has received oral or intravenous steroids to treat bronchospasm in the past month (Prednisone, Decadron, Dexamethasone or similar drugs). This does not include inhaled maintenance steroids, which do NOT preclude outpatient surgery at the ASC. i.e Steroid puff inhalers.
    3. c. Any asthmatic that has had an episode of wheezing or shortness of breath in the last two days.
  4. Patients included above will be considered for Outpatient Surgery (same day surgery) with discharge following their procedure if minimal sedation is given by the Anesthesiologist or CRNA only for the duration of the local or regional anesthetic needed to perform the procedure.
  5. If exceptions to this policy are appropriately based on the patientís history, the physician who gives the medical clearance must dictate the reasons for deviation from policy. Anesthesiologist/CRNA must also give clearance for the procedure to be performed.
  6. Anesthesia will not be administered until the attending surgeon is present and ready to perform the scheduled procedure.

Pre-Admission Testing Guidelines

Pre-operative laboratory testing should be based on the planned procedure, and the history and physical. The following guidelines are not intended to replace the clinical judgment of the physician. Some patients will require additional workup. If you have any questions about a particular patient, please discuss these with an anesthesiologist.

Test/Eval & Considerations For Performing

HCT or HGB    

History of anemia, potential significant blood loss
Valid within 1 month


History of cardiocirculatory disease or recent signs/symptoms
Valid within 6 months

Serum Chemistry    

History of renal disease
Valid within one week

Serum Potassium

Taking digoxin, diuretics, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers.
Valid within 24 hours of procedure

Coagulation Studies    

Required for patients taking anticoagulants
Valid within one week (if unstable, 24 hours)

Chest X-Ray    

History of CHF, cardiocirculatory disease, or recent URI
Valid within 1 year unless recent symptoms


If symptomatic of UTI