Lecture 1 1/14

Question 1

to bill for a level 5, how many HPI components do you need?

Answer 1

4

Question 2

What are the 8 things for HPI

Answer 2

Location
Quality
Severity
Duration
Timing
Context
Modifying factors
Associated signs and symptoms

Question 3

what allergies are most important for sx

Answer 3

Drug and latex

Question 4

How many ROS do you need to bill a level 5

Answer 4

10

Question 5

How many PE systems do you need to bill a level 5?

Answer 5

9

Question 6

where should you put that the procedure has been explained to the patient.

Answer 6

Plan

Question 7

What does ADC stand for? (Admit orders)

Answer 7

Admit to location (and who)
Diagnosis
Condition (good vs. fair vs. stable)

Question 8

What does VANDIMALS stand for? (Admit orders)

Answer 8

Vitals
Allergies
Nursing (strict I/Os, wound care, drain care, foley)
Diet (NPO, diet as tolerated)
IV (type and rate, boluses)
Meds (med, dose, route, frequency, indication)
Activity (walking qid, spinal precautions)
Labs
Studies

Question 9

do you need post-op labs for a straightforward procedure?

Answer 9

No, not typically

Question 10

What all goes on admit orders?

Answer 10

ADC VANDIMALS
call house office if: ……
Consent form (similar to plan)

Question 11

What is needed for an admit from ER to OR

Answer 11

ADC
Allergies
Diet IV
Meds
Labs
Consent

Question 12

What is included in a pre-op note?

Answer 12

Preop dx
Labs- 
ECG
Blood (type and screen) 
Bowel prep
PT NPO since MN
Anesthesia- preop and consent signed
Consent signed and in chart
Orders (abx)

Question 13

what is included in an operative note?

Answer 13

pre-op dx, post-op dx
Procedure
Surgeons (anyone present besides scrub tech)
Anesthesia (type) 
Fluids (type and volume) 
Urine output (total volume)
EBL (estimated blood loss)
Op findings (brief) 
Specimen (what was taken out, where sent)
Drain (type)
complications
Condition (extubated, intubated, to ICU)

Question 14

What is in Post Op orders?

Answer 14

ADC
VANDALISM
may need to change from oral to IV abx

Question 15

When is a post-operative note done?

Answer 15

Same day as surgery, but at least 6 hours later

Question 16

What is included in a post-op note?

Answer 16

Subjective
Objective
Vitals
I/O
PE- General Survey, CV, Lungs, Abd, Extremities
A/P (anything found, IV fluids, pain meds, abx duration, DVT prophylaxis, diagnostics needed)

Question 17

what does the daily progress note address? (subjective)

Answer 17

pain, N/V, activity level
pain meds used
Address BM, flatus, tolerating diet, CP, SOB, calf pain/ swelling, pt concerns

Question 18

What is always done for the objective part of the daily progress note/

Answer 18

Vitals
I/O
General Survey
CV
lungs
Abd (incision) 
Labs 
Imaging
Meds

Question 19

What can you do to indicate that labs are pending?

Answer 19

P with circle around if they aren’t back when you do your note

Question 20

What should be included in A/P for the daily progress note?

Answer 20

Anything found on H and P
Diet, IV fluids, pain meds
Foley, NGT, drains
Antibiotics
DVT prophylaxis
diagnostics

Question 21

What should be included in daily orders

Answer 21

basically copy from note

don’t write anything if it is going to continue