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Q4 EM Surg > Surgical Documentation > Flashcards

Surgical Documentation Flashcards

1
Q

Preop note includes?

ASIDB

A 
Admit/consult notes
Summary of relevant studies (lab, imaging)
Informed consent
Diet status
Blood product needs
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2
Q

Hospital Orders:

ADC VAANDIML

A 
Admit
Dx
Condition
Vitals
Allergies
Activity
Nursing orders
Diet
IV fluids
Meds (home and hospital)
Labs
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3
Q

Immediate PostOp Note includes?

PPPAAA OSPEU FCP

A 
Preop dx
Postop dx
Procedure
Attending
Assistants
Anesthesia type
Operative findings
Specimens removed
Pack/Drain/Catheters
Estimated blood loss
Urine output
Fluids given (incl blood, abx)
Complications
Pt disposition/condition
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4
Q

PostOp Rounding notes contain?

A

SOAP

*do not include pathology u/l documented by preceptor

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5
Q

Advanced Directives are?

Include?

A

Specific health care instructions in event pt can’t communicate their decisions

Living Wills
Durable POA

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6
Q

Living Will specifies?

A

w/drawl of tx if terminally ill and can no longer make decisions

Does NOT include w/drawl of nutrition or hydration

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7
Q

POA specifies?

A

Legal surrogate to make health care decisions for the pt if they are not able to

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8
Q

DNR orders are rescinded when?

A

during surgery

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Q4 EM Surg (27 decks)

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