Smith Lecture: OR Charting

Question 1

What needs to be in preop note?

Answer 1

• depends on hospital policy: simple statement updating PCP H&P stating that H&P is correct and there are no contraindication for surgery
• May need to do full H&P with heart and lung exam

Question 2

What needs to be listed on consent form?

Answer 2

• Procedure being done
  
  • do not use abbreviations, put in words that people can understand
• Potential risks and complications
  
  • legal standard is to list probable complications (more than 50% of time)

Question 3

what might be a part of preop orders?

Answer 3

• consent for surgery being performed
• preop antibiotics
• NPO midnight before procedure
• labs to be done before procedure

Question 4

What goes into a brief postop note?

Answer 4

SAPPPPAHEMIC

• surgeon
• assistant surgeon
• preop diagnosis
• postop diagnosis
• procedure
• pathology (and cultures or specimens sent)
• anesthesia (general or local)
• hemostasis (tournique type, presure and time)
• estimated blood loss
• materials (any scres, plates, sutures, etc)
• injectables (local or steroids)
• condition (was pt stable at end of case?)

Question 5

what goes into a full operative note?

Answer 5

• SAPPPPAHEMI and ….
• positioning
• sterile prep
• tournique application
• timeout
• procedure detail
  
  • incision length and location, dissection, what was performed, irrigation, closure, dressings, etc

Question 6

what goes into post-op orders?

Answer 6

ADCVANDILMAX

Admit: where, to whom

Dx: status post op of ….

Condition: stable

Vitals

Activity: NWB, w/ crutches

Nursing: ice and elevate

Diet: regular

I+O: IV until taking PO fluids

Labs:

Meds:

Ancillary: PT?

X-ray:

Question 7

what goes into progress note?

Answer 7

SOAP note on a patient in the hospital (what you write after visiting them that day)

Question 8

what goes into discharge note?

Answer 8

discharge orders, f/u information

Question 9

hospital discharge summary

Answer 9

date of admit

date of discharge

principal diagnosis

secondary diagnosis

operative procedutres

consults

summary of stay

condition of pt upon discharge

discharge instructions

Question 10

orders for outpatient surgery

Answer 10

dressing instructions

WB status

activity instructions

xray

pain med

f/u instructions

durable medical equipment DME