Surgery Overview Outline Flashcards
Questions
Answers
Supplements that can cause bleeding problems
Gingko biloba; garlic; ginseng; fish oil (omega-3 fatty acids); Dong quai
OTCs that can cause bleeding problems
Aspirin, Aleve, Advil, Motrin, Vitamin E
Supplements that can have cardiovascular effects
Ephedra (causes HTN, palpitations, & tachycardia)
Garlic (causes HYPOtension)
Supplements that can cause drug interactions
Echinacea, Goldenseal, Licorice, St. John’s Wort; Kava, Valerin
Supplements that can have anesthetic effects
Valerian, St John’s Wort, Kava
Required contents of signed consent
Procedure & location (Right TKR)
Alternative procedures that will be decided intra-operatively
Risks, benefits, and potential complications
Signatures of patient, surgeon, and whomever consented the person
Post Procedure Note
Note written immediatelyafter surgery, including patient’s condition prior to transfer to PACU, allowing patient care providers to know immediate information pertaining to the surgical patient. This is a JCAHO requirement but does not replace the operative note.
Operative Note
Legal document required within 24 hr of surgery; must be completed by physician and include “play-by-play”. Template for routine surgeries may be employed by doctors.
Required components of admission order
Admit/Transfer
Diagnosis at admission
Vitals (how often)
Allergies
Nursing (Diet/IV)
Condition
Exercise
Labs
When to call
Daily Progress Note
Use SOAP format. Check the following before morning rounds. On afternoon rounds, report any significant events. However, don’t wait for afternoon rounds to report something significant.
Examined components during morning rounds
Appearance
Vital signs
Output
Input
Drains
Wound/Dressing/weight
Temperature
Examination
ICU note timing
Before morning rounds. Thorough & systematic. Plan to spend at least 30 minutes per patient for your exam and note writing.
Discharge Summary Contents
Summarizes:
Admitting diagnosis
Discharge Diagnosis
Diagnostic procedures
Therapy received
Clinical course
Prognosis
Discharge instructions (diet, activities, medications, follow-up).
Short stay form is completed for hospitalization
Presenting on Rounds
Be concise. Never lie or hedge. Never whine. Be a team player. If you don’t know, “I do not know, but I will find out.”
Round Presentation Contents
Patient name
Post-op day & procedure
Significant events in past 24 hr
Vitals/temp/24 hr output
ABX and day of ABX
Pertinent labs
Pertinent change in PE
Any complaints
PLAN!
Timing of Admission H&P
within 24 hr of admission
Informed Consent Timing
within 30 day of surgery; must be witnessed by someone NOT on surgical team
Pre-Op H&P timing
within 30 days of surgery, updated on surgery day
Post-op note timing
immediately after surgery
Post-op orders timing
immediately after surgery
Operative note timing
within 24 hr of surgery completion
Progress note timing
daily by each service treating patient
Order timing
daily
Discharge summary timing
Handwritten form complete if stay less than 48 hr; dictated if > 48 hr
Rules of Paperwork
PA should fill out all paperwork possible. Only paperwork legally obligated to surgeon = operative note. Everything requires time/date stamp.
