SURGICAL CHARTING Flashcards
most notes follow?
SOAP note
what is the most important part of the subjective part of SOAP?
NLDOCAT
what is the most important part of the SOAP note?
the plan
in the surgical physical exam, what do we need to know?
pulses, cap fill, time, hair growth
if absent, order an ABI; additional neuro exam performed like neurovib, ect
T/F, surgical consent must be done by the physician?
T
important pre op orders?
tell pt no eating; preg test
labs, x-rays, EKG, evaluate risk
surgical site prep
what is included in the post-op orders?
VANDILMAX
vitals, activities, nursing, diet, I/O, labs, meds, ancillary, x-ray
admission orders, more specific: admit to, diagnostic, condition so add ADC to above
when should the post op be written?
immediately after the surgery
most important part in discharging the patient?
instructions
when is phone dialogue with patient conducted, like a follow up?
day after
personally call the patient; and document it
