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دليل السياسات والإجراءات في غرفة العمليات
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→ F-OT-11
F-OT-13 ←
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General Hospital • Operating Theatre
OT Cancellation Form
F-OT-12
Patient Name
MRN
Ward / Location
Intended Procedure
Surgeon / Team
Cancellation Details
Date of Cancellation
Time
Cancelled By (Name / Role)
Stage of Cancellation
Prior to Day of Surgery
Day of Surgery (Patient on Ward/Holding)
Day of Surgery (Patient inside OR/Induction)
Reason Codes
Select Primary Reason
100 - Patient Clinical
101
Acute medical illness / Change in condition
102
Unfit for anesthesia (Cardio/Resp review)
103
Surgery no longer indicated (clinical decision)
104
Abnormal lab results / Investigations on DOS
200 - Patient Non-Clinical
201
Did Not Attend (DNA) / Absent
202
Fasting violation (NPO non-compliance)
203
Patient refused surgery / Withdrew consent
204
Patient arrived late (caused list overrun)
300 - Facility & Operations
301
OT time ran out / Previous case overran
302
No ICU bed / Post-op bed available
303
Emergency case took priority (List bumped)
304
Surgeon / Anesthetist / Key Staff unavailable
305
Equipment failure / Missing sterile instruments
400 - Workup & Documentation
401
Incomplete pre-op workup / Consults missing
402
Consent missing or invalid (could not be resolved)
403
Blood products required but unavailable
404
Specific implant / prosthesis not available
Additional Remarks / Explanation
Post-Cancellation Actions
Rebooking Plan
Rebooked
Not Rebooked / Discharge
New Date (if known)
Escalation / Notification (Check all that apply)
Patient / Family Informed by Surgeon
Ward / Admitting Unit Notified
OT Manager / Medical Director Notified
Cancelling Physician / Surgeon
Name / ID
Signature
OT Charge Nurse / Coordinator
Name / ID
Signature