Chap 8 Flashcards
What is the purpose of daily rounds?
The purpose of the daily visit is to see how patients are responding to treatment and to determine whether any new problems have arisen.
When is documentation required?
Remember that documentation of an admission history and physical examination (H&P) is required within 48 hours of hospitalization
What is included in the daily progress note?
medical admissions
surgical admissions
What should you always do and record in the daily progress note?
Some of the physical exam
HAVE to do heart and lungs
also always do general survey and VS
How do you document a post op patient
POD day ______
What is the most common post op problem? What is it caused by?
Fever;
respiratory, wound, or urinary tract infection, thromboembolic event, or drug side effect
What should you include in a daily progression note for a post op patient?
the surgical incision or operative site should be inspected, and the appearance should be described in the note. Document the presence of any drains and the amount and color of any drainage. If the patient had general anesthesia, it is important to determine return of peristalsis.
Once you have assessed the patient and recorded the daily progress note what should you do?
you should write orders that correspond to any changes addressed in the plan.
What is an operative report?
A full operative report, which provides a detailed narrative of the surgical procedure,
Who dictates the full operative report?
surgeon
What form is the op note in?
hand written
What does the op note include?
Date of procedure Name of procedure Indication: reason for the procedure Surgeon Surgical assistants Anesthesia: local, general, regional; name of person administering anesthesia Preoperative diagnosis: Postoperative diagnosis: Descriptions 1. Specimens: what tissue was removed and what studies were done 2. Estimated blood loss (EBL) 3. Drains: types of drains, if any, and where placed Complications Disposition
What is the purpose of a procedure note?
The purpose of the procedure note is to document why and how a procedure was done and the patient’s response to the procedure.
What is included in a procedure note?
Name of the procedure Indication for the procedure Consent (name and relationship of person giving consent) Anesthesia (if applicable) Details of the procedure Findings (if relevant) Complications
What is the purpose of a delivery note?
A delivery note is used to document the outcome of an obstetrical admission.
