Surgical Documentation

Question 1

Included in the PRE-OP note

Answer 1

date & time

pt. information
- name, MR#, DOB

Pre-op Dx.
- example (appendicitis)

Procedure
- example (laproscopic appendectomy)

Labs
- pertinent (CBC, CMP, etc.)
- T&S
- CXR and EKG (if indicated)

Orders
- NPO (after midnight, clears, etc.) now? date? time?
- IVF with rate/HR (commonly LR, NS) : watch in HTN
- DVT prophylaxis (subQ heparin, etc.)
- consent signed in chart
- ABX. prophylaxis

additionally add..
- ASA Classification for surgery
-any pertinent PMHx.

SIGN DATE AND TIME

Question 2

Intraoperative Note and Brief Note

Answer 2

the Surgical Note will be written by the surgeon
- name, date, time, identifiers
- procedure
- surgerons and personell
- indications (a brief HPI)
- preop dx.
- postop. dx.
- findings
- anesthesia
- fluids
- estimated blood loss
- drains
- complications
- pathology
- dispostion : desribed pt. condition
- procedure: in detail
___________________________________________________
but the PA (you!) will write the brief note = a condensed surgical note

a Brief -Op Note
pt name & identifiers
date and time
pre-op dx.
post-op dx.
procedure done
people (surgeon, assist, etc.)
findings in surgery
anesthesia type
estimated blood loss
speicmens
wound classification
complications
dispoe (where is pt. going, –pacu)
signs

Question 3

Post - Op Note

Answer 3

date and time

pt. identifeirs

short HPI about the pt. s/p procedure
(example xxx s/p appendectomy)

subjective information:
- subejctive
- brief ROS
- include pain
- respiratory status
- any N/V?
- cardiac symptoms?
- any other peritinenet symptoms
- interval history: no significante event since the OR or during PACU

Vitals

Physial Exam
- LOC, lungs, CV, ABD, and any other pertinents
- note incision C/D/I
- swelling, bursing, bleeding
- drains,cast, bandages

assessment (similar to opening statement) POD0
plan
- pain management
- abx.
- diet
- fluids
- DVT pro.
- spirmeetry
- labs to order
- drain and wound care
- drains (color, amoutn)
- acitivty and followup

sign

Question 4

Progress note

Answer 4

done on the floor POD 1, 2, etc. in the hosptial

date and tiem

pt. indetifners

short HPI: s/p and procedure POD

sujective information with ROS
- pain
- resp.
- N/V
- cardiac
- peritents
- interval history since procedure

VS

PE
- LOC
- lungs, CV, ABD
- pertinets
- incision C/D/I
- swelling, bursing bleeding
- drains (report)
- casts, banages, etc,

assessment (repeat bascailly iopening statement)

plane
- pain meds
- abx.
- fluids and diet
- dvt pro.
- spirmetry
- labs to order (if there, document after PE)
- drains
- woudner care
- activity and follow ip
- how your mamanging comoribities
- and meds given

sign