HOW TO ADMIT AND HOW TO PREPARE FOR ADCON

from Group 21 BRONERS :)

Department of Ophthalmology
Quirino Memorial Medical Center

1. As a rotating clerk in Ophtha, you will be assigned patients who are due for admission and
surgical procedures. You will be the clerk-in-charge for the patient so you will have to follow
them from the time they are admitted to the time they have the procedure (you will most
likely do pre-op assessment, scrub in the surgery) and until they are examined post-op up
to discharge.
2. Your resident will inform you about patients due for admission the day before. You have to
assign among yourselves in your duty group who will take which patient so that the time
they will arrive in the Eye Center OPD the next day for admission, you can directly do your
interview, accomplish paperwork, and refer for admission.
3. On the day of admission, as soon as your patient arrives in the OPD, inform your resident
and ask if you can already start the interview and accomplish admission paperwork. The
residents WILL NOT inform you if your patient for admission already arrives, so BE IN THE
LOOKOUT. Ask the nurse on duty at the front desk or ask the first year residents (Doc BJ
or Doc Nina).
4. When your patient arrives:
a. Introduce yourself as the clerk-in-charge and you will be the one who will constantly
follow up the pt
b. Do COMPLETE history (with emphasis on details that are significant for your case eg
cortical cataract - Hx of chronic steroid use) and OPTHA PE (VAGETSF). This is
important for your AdCon Presentation. Do ROS as well.
c. Complete admission form as BRIEFLY as possible.
 d. Perform initial slit lamp examination. After documenting findings, call a resident (usually
Doc Nina/Doc BJ, Doc Emil/Doc Sobrio puwede din) to take a second look. Ask if you
can use the slit lamp with the camera. PRE-OP SLIT LAMP EXAM PHOTOS ARE
REQUIRED IN YOUR ADCON PRESENTATION, so be sure to do this!
e. Your resident will now fill out the doctors orders form. Either the resident will dictate and
you will write whatever they say, or the resident will just do it on their own. Either way,
be sure to observe/take note of the orders (eg IV medications, NPO instructions, pre-op
medications)
f. IMPORTANT: Make sure to explain to the patient the consent form for the surgery.
Explain the surgery to the patient or to the bantay, and then explain the risks. Have
them SIGN the consent form.
g. The nurse will perform VS, ht and wt on the patient. Be sure to take note of these as
well, for your adcon presentation.
h. IMPORTANT: Check if CP clearance paperwork are already complete such as CXR,
ECG, labs, etc. Be sure that they are included in the admission charts.
i. Once everything is done, accompany the patient together with the nurse to the ward
where he will be admitted.
5. Monitor the VS chart of the patient every 6 hours or at least once or twice before the
surgical procedure. Check for red flags/drastic changes, for fever, for hypotension, etc.
Check if doctors’ orders are carried out by the nurse on duty (usually it is annotated in the
charts that they are already carried out).
6. On the day of surgery, ask the resident-in-charge who will perform the procedure if you may
observe/scrub in since you’re the clerk in charge. BE SURE TO STUDY THE SURGERY/
OPERATIVE TECHNIQUE THAT WILL BE USED (eg for cataract- phacoemulsification).
Study eye anatomy as well.

7. Take note of the surgical report who is usually filled out by the scrub nurse. Ask the nurse if
you can just take a look, you might find important info for your presnetation such as
complete name of procedure, what lens will be implanted, equipment to be used, etc. Also,
take a look at the pre-op passport/checklist for vitals, other info.
8. POST OPERATIVELY,
a. You will discuss the surgery with the resident. Be proactive in the discussion and share
your observations.
b. You will be the one to write the post-op doctors orders such as medications. Be sure to
take note of them because you will be the one to instruct the patient/bantay about this in
the ward.

c. Visit patient to check for post-op complaints eg pain, inflammation, redness and note
this in the chart, if present. Also, if red flags are present, inform resident on duty ASAP.

d. Post-op hospital day 1 - first hour in the morning, your

resident will perform post-op visual acuity assessment and slit
lamp examination on your patient. TAKE NOTE OF THE
POST OP FINDINGS because this will be included in your
presentation. If possible, take photos of slit lamp findings
post-op. If not, just include a rough schematic diagram.

e. If patient is for discharge, ACCOMPLISH (1) DISCHARGE

SUMMARY and (2) TAGUBILIN SA PASYENTE. Your
resident will usually instruct you what to put in
the tagubilin, but this is usually instructions for
eye care and more importantly, HOME
MEDICATIONS. Discharge summary is
basically just identifying information, brief
clinical history and PE, procedure done, and
course in the wards. Your resident will teach
you how to do this.

PREPARE YOUR ADCON PRESENTATION WITH

ALL THE INFORMATION YOU HAVE GATHERED
FROM THE TIME PATIENT WAS ADMITTED TO
THE TIME HE WAS DISCHARGED.

ADCON FORMAT IN ANOTHER PDF *