1. Unit 5: Communication
1.1. Communication Challenges
1.1.1. Health Literacy Issues
1.1.1.1. Several patients don’t know about the complex medical terms and procedures, particularly during surgical procedure. Their lack of health literacy can make it difficult for them to know about the treatment programs and make informed decisions regarding their care
1.1.2. Emotional and Psychological
1.1.2.1. Patients may feel stressed, fearful, or anxious about their surgical procedures, which could prevent them from communicating openly with healthcare personnel. These emotions may prompt them to keep information or mistake medical advice, resulting in unsatisfactory outcomes.
1.2. Communication Device
1.2.1. Communication Board
1.2.1.1. A communication board in a general surgical unit allows nonverbal or post-surgical patients to express requires such as pain, or discomfort using symbols and letter. It promotes communication among patients, healthcare practitioners, and families, so increasing patient comfort and care coordination, particularly when spoken communication is difficult
2. Unit 6: Patient Record
2.1. Transcription Reports
2.1.1. Hostory and Physical Reports
2.1.1.1. This report is generated during a time of patient’s admission in the hospital that covers their medical history, present signs and symptoms, and physical examination findings. This report is necessary for further treatment or planning of surgery and post-operative care.
2.1.2. Operative Report
2.1.2.1. This report provides the details of the surgical procedure performed on the patient. The report also describes the procedure conducted, including preoperative and post operative diagnosis, surgical procedure used, and the patient’s postoperative care. This report is essential to record the surgical history and post operative treatment.
2.1.3. Discharge Summary
2.1.3.1. This is the report or document that is prepared when patient is getting discharge from the hospital or healthcare facilities. This report provides details about the patient’s hospital stay, admission and discharge diagnosis, treatment provided by the hospital, the patient progress and follow-up instruction and care after discharge.
3. Unit 7: Admission, Transfer and Discharge
3.1. Admission Process
3.1.1. Elective Admission
3.1.1.1. It is a planned admission which are non- emergency and patient are schedule in advance for surgeries such as hernia repair or joint replacement.
3.1.2. Emergency Admission
3.1.2.1. This admission is often sudden, and unexpected in urgent cases like appendicitis, trauma, or perform ulcers requiring immediate surgery.
3.2. LOS
3.2.1. The average length of stay (LOS) for patient in a general surgical unit varies based on the specific type of surgical procedure. The LOS can range from approximately 2 to 6 days depend on the procedure.
3.3. D/C Supports
3.3.1. Home Care Service
3.3.1.1. Make sure to do wound care if have an incision or cut to be free from infection. Look for the daily activities’ restriction instruction and diet plan that include protein rich food, helps for wound healing and recovery.
3.3.2. Prescription
3.3.2.1. Patient will prescribe medication for the pain management, infection control in the wound.
3.3.3. Follow-up Procedure
3.3.3.1. Follow-up treatment is necessary to monitor the condition and address any complication with the GP.
4. ReferenceWeatherhead, N. (2025). Overview of the HUC Role – Hospital Unit Administration. Conestoga Open Learning. Nursa. (2023, September 29). What Is a Surgical Unit in a Hospital? Stanford Health Care. (n.d.). General Surgery - Common Surgical Procedures | Stanford Health Care. Weatherhead, N. (2025). Emergency and Surgical Services – Hospital Unit Administration. Conestoga Open Learning. Fredricks, A. (2024, Jan 16). The 5 Nurse Staffing Models: Which One is Right for You?. Makeshift. Wolters Kluwer. (2016, November 11). The Importance of the Optimal Nurse-to-Patient Ratio | Wolters Kluwer. Yukon Hospitals. (n.d.). Inpatient Units | Yukon Hospital Corporation. Weatherhead, N. (2025). Staffing and Scheduling Provisions in a Collective Agreement – Hospital Unit Administration. Conestoga Open Learning. High Surgery. (2024, July 22). Understanding the risks of general surgery - HighSurgery. Thehealthwale. (2024, December 23). Hospital Emergency Codes: A Comprehensive Guide – Thehealthwale. Daniell, B. (n.d.). Communication Barriers in Healthcare and How to Overcome Them. Dialog Health. Weatherhead, N. (2025). Other Communication Devices – Hospital Unit Administration. Conestoga Open Learning. KamelBPO. (2023, July 13). A Guide on 20 Types of Medical Reports That Often Require Transcription | KamelBPO. Davis, C. P. (n.d.). Hospital Admissions: Advance Directive, Patient Rights, Tests. eMedicineHealth. Canadian Institute for Health Information. (2024, February 22). Hospital stays in Canada, 2022–2023 | CIHI. Winnipeg Regional Health Authority. (n.d.). General Discharge Instructions for Surgical Patients and Families | Winnipeg Regional Health Authority. Griffin Concierge Medical. (2022, November 15). Which Cardiac Tests Should You Get BEFORE a Surgery?. Venturi Cardiology. (n.d.). Tests Before Heart Surgery | Pre-Op Testing | Private Cardiac Diagnosis. Rochester Regional Health. (n.d.). Tests Before Your Surgery | Rochester Regional Health.
5. Unit 8: Confidentiality and HIM
5.1. Outside Providers
5.1.1. Preoperative Cardiac Evaluation Reports
5.1.1.1. This may help to ensure patient’s cardiac health before surgery highlighting possible issue like heart disease or abnormalities that might complicate the operation. These examinations are often conducted by cardiologists or specialized cardiac clinic. If the examination is done and knowing a patient heart condition is not good for surgical preparation and anaesthesia treatment. It will help to identify and prevent preoperative cardiac problems, which help for patient safety.
5.1.2. Diagnostic Imaging Reports
5.1.2.1. Diagnostic imaging can be done varies upon the condition of patient such as MRI and CT scans, provide all the information of internal views that can help for the diagnosis and surgical preparation like tumors. Another one is ultrasound imaging can help to evaluate soft tissue, detect abnormalities like appendicitis, kidney stone, gallstone which help surgeon plan procedure accordingly. If the patient condition is related to fracture, joint dislocation or lungs condition like asthma and pneumonia and coronary artery disease X-ray imaging can be done to detect the condition and ensuring safer surgical planning. This imaging can be done in radiology department, diagnostic imaging center.
6. Unit 1: Health Care professional
6.1. MRP/Consultant
6.1.1. General Surgeon
6.1.1.1. A general surgeon is a physician who help in the preoperative diagnosis, perform surgical procedures, and manage the post operative care.
6.1.2. Anesthesiologist
6.1.2.1. Look for anesthesia during surgery to ensure that patient remain unconscious or with no sensation. Monitor patient vitals and help in the pain management outside the operative room.
6.2. Nursing Staff
6.2.1. Registeres Nurse
6.2.1.1. Registered nurse is a healthcare provider who provide primary care of patients in acute and critical care areas. Perform different task including physical examination, prescribe medication, perform minor dressing and provide health education.
6.2.2. Operative Room Nurse
6.2.2.1. Assist patient during surgery and help the surgeon
6.3. Allied HC Worker
6.3.1. Physiotherapist
6.3.1.1. Help patients to develop strength, mobility, balance, coordination and joint range of motion after surgery which include exercises, massage, occupational retraining.
6.3.2. Pharmacist
6.3.2.1. Provide medication to all the patients ensuring correct medication, dosing and guidance to use the medication safely and effectively.
7. Unit 2: Organization of Hospital/Care Unit
7.1. ID of Department
7.1.1. Inpatient department
7.2. Purpose/Diagnosis
7.2.1. Purpose
7.2.1.1. General surgical unit provide surgical intervention for both acute and chronic condition requiring operative management.
7.2.2. Medical Diagnosis
7.2.2.1. Appendicitis
7.2.2.1.1. It is the acute inflammation of appendix. The surgical procedure for appendicitis is appendectomy (removal of appendix).
7.2.2.2. Cholelithiasis
7.2.2.2.1. Surgical procedure is cholecystectomy (Removal of gallbladder due to pain or infection).
7.2.2.3. Hernia
7.2.2.3.1. Surgical procedure is hernia repair (Repaired the weakened abdominal muscles)
7.3. Organization Structure
7.3.1. Under Surgical Services
8. Unit 3: Staffing and Scheduling
8.1. Staffing Pattern and Staffing Ratio
8.1.1. Staffing Pattern
8.1.1.1. Primary Nursing Care: In this model, one primary nurse oversees managing a patient's care from admission to discharge, providing stability and an individualized approach. Given the increased intensity and variety of cases in a General Surgical Unit, the primary nursing model is frequently used to offer continuous and comprehensive care.
8.1.2. Satffing Ratio
8.1.2.1. General Surgical Unit, the staff-to-patient ratio generally runs between 1:5 and 1:6. This implies one nurse is responsible for five to six patients per shift. These ratios are intended to combine patient safety with sustainable workloads for nurses, thereby ensuring quality care and decreasing stress.
8.2. Coverage
8.2.1. In general surgical unit where patient stay overnight or are inpatient requires 24/7 nursing coverage that is essential to ensure patient receive timely care and monitoring. This around the clock care that addressing postoperative complication, provide essential needs and support for recovery or during emergencies and pain management
8.3. Premiums
8.3.1. Night shift premium
8.3.1.1. Night shift workers usually work between 11 p.m. to 7 a.m. that frequently receive additional income. This additional payment motivates employees to work less preferred hours, ensuring that the staff is full in the unit at all the shifts.
8.3.2. Weekend Premium
8.3.2.1. Weekend shift worker usually from Friday night to Sunday night that are frequently paid extra. This helps maintain enough staffing level during weekends, when it may be more difficult to find workers on the shifts during weekend
9. Unit 4: Risk Management
9.1. Specific Risk
9.1.1. Post-Operative Infection
9.1.1.1. Patients in a General Surgical Unit are more likely to develop surgical site infections, which may cause problems and extended stays in the hospital. Maintaining sterile methods and infection detection are essential for infection control
9.1.2. Deep Vein Thrombosis
9.1.2.1. General Surgical Unit patients, particularly those who don't mobilize, are at risk for blood clots forming in deep veins. Early mobilization techniques, Prophylactic anticoagulants, Compression stockings can help to reduce this risk.
9.2. Hospital Codes
9.2.1. Code Red
9.2.1.1. Fire emergency. Hospitals must be prepared for fire hazards, ensuring patient safety. Where general surgical unit contain specialized equipment such as oxygen containers and electronic equipment’s that might cause fire hazards.
9.2.2. Code White
9.2.2.1. Indicates a violent or aggressive individual. Like after surgery because of anesthesia, pain medication or due to medical condition patient might become confused, agitated or delirious. At that time code white ensure that qualified workers can safely calm down aggressive behavior and protect staff as well as patient.
9.2.3. Code Blue
9.2.3.1. Medical emergency- cardiac or respiratory arrest. In surgical unit like postoperative patient might develop the problems like respiratory distress or reduction in blood pressure. Code blue helps to get a rapid response from the team that can perform life saving management