Surgery Packet

NHOC’s Opioid Prescribing Policy
Your physician is prescribing an opioid medication as part of your treatment. It is important to remember the following when taking your medication:
- Take your medication exactly as prescribed.
- Read all instructions that come with your medication.
- Using this drug may cause addiction. While addiction is more common in people with a personal or family history of addiction, it can occur in anyone.
- Taking more than the prescribed amount of medication or using with alcohol or other drugs can cause you to stop breathing resulting in coma, brain damage, or death.
- Opioids can slow reaction time, cause drowsiness, or cloud judgment. It may be unsafe for you to drive or operate heavy machinery while taking your medication.
- Opioids are at risk of being diverted by anyone with access to your home. Opioids should be stored in a safe and secure place, such as a locked cabinet or safe.
- Unused opioids should be disposed of according to the label or patient information. If there are no specific instructions, medications may be returned to a take-back location or mixed with a small amount of water and an undesirable waste substance such as used coffee grounds or cat litter.
NH STATE LAW states that we are unable to prescribe opioids for a period of time greater than 3 months. In the rare case a patient continues to require opioid medication for pain control the patient will need to be referred to their PCP or a Pain Management Specialist.

For NHOC patients on Narcotics - please be aware that you are prohibited from getting narcotics from any other provider if you are receiving a narcotic prescription from a NHOC provider

For more details visit the New Hampshire Statutes Controlled Drug Act website: Click Here
Opioid Prescription Informed Consent
Patient Name*
First Last
Birthdate*
MM slash DD slash YYYY
Gender*
- Male
- Female
Your provider is prescribing an opioid (pain) medication as part of your ACUTE treatment. Opioids can help with ACUTE pain control if used carefully and for the shortest duration possible. Larger doses and longer duration of therapy increase risks. It is important to remember the following when taking your medication:

Take your medication exactly as prescribed, and read all the instructions that come with your medicine.
- Side Effects: Ingestion of controlled opioid medications may lead to: confusion, drowsiness, dizziness, nausea, constipation. These are not allergic reactions. However, on rare occasions patients will experience an allergic reaction which may include: swelling of the face or throat, chest tightness, hives or shortness of breath.
- Using this drug may cause addiction. While addiction is more common in people with a personal or family history of addiction, it can occur in anyone.
- Taking more than the prescribed amount of medication or using with alcohol or other drugs can cause you to stop breathing resulting in coma, brain damage, total disability or death.
- Opioids can slow reaction time, cause drowsiness, or cloud judgment. It may be unsafe for you to drive or operate heavy machinery while taking your medication.
- Opioids are at risk of being diverted by anyone with access to your home. Opioids should be stored in a safe and secure place, such as a locked cabinet or safe.
- Opioids may increase risk of victimization. There is a risk that you or members of your household may be subject to theft, deceit or assault or abuse by persons seeking to obtain your medications for purposes of misuse.
- Pregnancy: Opioid medications can pose a deﬁnite health risk to the fetus in pregnant women. Some opioid medications are permitted with caution, but studies are scarce and therefore, potential for harm to the fetus may still exist. In addition, chronic use of these medications during pregnancy can lead to the baby being born addicted to the medication, complete with withdrawal symptoms.
- Unused opioids should be disposed of according to the label or patient information. If there are no specific instructions, medications may be returned to a take-back location or mixed with a small amount of water and an undesirable waste substance such as used coffee grounds or cat litter.
- I have read this document and have had the opportunity to have my questions answered. I understand the risks and benefits of opioid treatment and accept the responsibilities described above.
Patient Signature*
Date*
MM slash DD slash YYYY
NHOC Surgical Scheduling Process
Patient Name*
First Last
Birthdate*
MM slash DD slash YYYY
Gender*
- Male
- Female
Your surgeon has ordered surgery for you. We appreciate your confidence in our staff and we will work hard to ensure that scheduling your surgery will go as smoothly and efficiently as possible.

To this end we would like to share our process with you and what may be involved in securing your surgery date.

We strive to contact our patients within 72 business hours of date and time the order was generated and we book surgeries chronologically by the date and time they were ordered. (Unless your surgery has been ordered as URGENT in which case you will hear from us within 24 business hours). We thank you for your patience as our staff works hard to secure a date for your surgery.

NHOC staff will contact your insurance company to verify benefits as well as ascertain information regarding any financial obligation you may incur. This information will be shared with you to allow you to make an informed decision to proceed with the surgery and put payment arrangements in place. (If the main contact number you have provided to us is a cell phone please make sure that your voicemail is set up and that there is enough memory to allow us to leave a message letting you know that we are trying to reach you.)

Once financial obligations have been discussed and payment arrangements have been put in place we can assist you with selecting a surgery date. The surgery coordinator will contact you to review your health history and current medications and advise you if preoperative testing and/or clearance(s) need to be performed. This could include visits with your Primary Care Physician, Dentist and/or any specialist that you are currently treating with; or have treated with in the past; to ensure that you are in the best possible health to proceed with the surgery ordered.

While you are getting all your testing and clearances done NHOC will be working with your insurance company to ensure that prior authorization or precertification for your surgical procedure is in place before your surgery date. If you have any questions or concerns, please to not hesitate to contact our office.

PATIENTS HAVING SURGERY AT BASC OR NASC PLEASE NOTE:

If your surgeon is going to perform your surgery at Nashua Ambulatory Surgery Center please log on to www.bascnh.com\nashua and click on 'Patient-Registration' to go to One Medical Passport. If you are a first time user of One Medical Passport you will need to register by clicking on the green Register button. Please answer all the questions on each page, click save and continue. Please visit this site and do the online registration as soon as possible so that we can properly plan for your surgical procedure while taking all of your health history into consideration.

If your surgeon is going to perform your surgery at Bedford Ambulatory Surgery Center please log on to www.bascnh.com and click on BASC (Bedford) then and click on 'Patient-Registration' to go to One Medical Passport. If you are a first time user of One Medical Passport you will need to register by clicking on the green Register button. Please answer all the questions on each page, click save and continue. Please visit this site and do the online registration as soon as possible so that we can properly plan for your surgical procedure while taking all of your health history into consideration.

Sincerely,
NHOC Surgery Coordinator Team
NHOC’s Disability Form Completion Policy
Patient Name*
First Last
Birthdate*
MM slash DD slash YYYY
Gender*
- Male
- Female
The New Hampshire Orthopaedic Center staff and physicians will be happy to assist you in the completion of your disability forms. Due to the volume of the forms that are received, the following criteria apply:
- The patients portion of the form must be completed and signed.
- The form will be completed within 10 business days from the date it has been received in the office.
- By signing this form, you are allowing New Hampshire Orthopaedic Center to release information pertaining to your injury to your insurance company or employer.
For patients requesting Family Medical Leave Act (FMLA): Are you planning to be out of work for a continuous amount of time or will there be an intermittent leave to attend physical therapy or doctors appointments?
Please choose: Continuous or Intermittent*
- Continuous
- Intermittent
Treating Physician*
Date of Injury*
MM slash DD slash YYYY
Job Description*
What aspects of your job are affected by your injury*
When did you stop working due to this condition*
Usual number of hours per day*
Usual number of hours per week*
When the disability form is completed*
- Please call me and I will pick up the completed form
- Please fax the form
- Please mail the form
Choose Office Location*
Fax Number*
Attention*
Please mail the form to*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient or Authorized Signature*
Date*
MM slash DD slash YYYY
Relationship to Patient*
WOMAC Osteoarthritis Index
* This form is only to be completed by patients having a total knee or total hip replacement *
Patient Name*
First Last
Birthdate*
MM slash DD slash YYYY
WOMAC Osteoarthritis Index

Overview: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was created to assess pain, stiffness, and physical function in patients with hip and / or knee osteoarthritis (OA). The WOMAC consists of 24 items divided into 3 subscales:
- Pain (5 items)
- Stiffness (2 items)
- Physical Function (17 items)
Number of items in scale: 24 items The WOMAC is available in 5-point Likert-type and 100mm Visual Analog formats.
Section A: PAIN

Think about the pain you felt during the last 48 hours caused by the arthritis in your knee or hip. Select the number that best describes your pain.
How much pain have you had*
None Mild Moderate Severe Extream
When walking on a flat surface
When going up or down stairs
At night while in bed? (pain that disturbs your sleep)
While sitting or laying down
While standing
Section B: STIFFNESS

Think about the stiffness (not pain) you felt during the last 48 hours caused by the arthritis in your knee or hip. Stiffness is a sensation of decreased ease in moving your joint.
Select the number that best describes your stiffness*
None Mild Moderate Severe Extream
How severe has your stiffness been after you first woke up in the morning
How severe has your stiffness been after sitting or lying down or while resting later in the day
Section C: DIFFICULTY PERFORMING DAILY ACTIVITIES

Think about the difficulty you had in doing the following daily physical activities during the last 48 hours caused by the arthritis in your knee or hip. By this we mean your ability to move around and take care of yourself.

How much difficulty have you had*

	None	Mild	Moderate	Severe	Extream
When going down the stairs
When going up the stairs
When getting up from a sitting position
While standing
When bending to the floor
When walking on a flat surface
Getting in or out of a car, or getting on our off a bus
While going shopping
When putting on your socks, panty hose or stockings
When getting out of bed
When taking off your socks, panty house or stockings
When lying in bed
When getting in or out of the bathtub
While Sitting
When getting on or off the toilet
While doing heavy household chores
While doing light household chores

SCORING

Each scale uses the following descriptors for all items: none, mild moderate, severe, and extreme. These correspond to an ordinal scale of 0-4. The scores are summed for items in each subscale, with possible ranges as follows: pain=0-20, stiffness=0-8, physical function=0-68. A total WOMAC score is created by summing the items for all three subscales. (0-96) Interpretation of Scores: Higher scores on the WOMAC indicate worse pain, stiffness, and functional

	None	Mild	Moderate	Severe	Extream
How severe has your stiffness been after you first woke up in the morning
How severe has your stiffness been after sitting or lying down or while resting later in the day

NHOC’s Opioid Prescribing Policy

Opioid Prescription Informed Consent

NHOC Surgical Scheduling Process

NHOC’s Disability Form Completion Policy

WOMAC Osteoarthritis Index

Contact us to learn more about your treatment options