Surgical Note Flashcards
1
Q
What is the acronym to remember admission orders?
A
ABC Vandalism
A; admit (where)
B: Dx (Because)
C: condition
V: vs A: allergies N: nursing orders D: diet A: activity L: labs I: IV fluids S: Studies M: medications
2
Q
What are the post op orders?
A
Similar to admission orders but more specific to operative procedure, includes:
- Drains
- Incision
- pain management
- n/v management
- DVT prophylaxis
3
Q
What is SOAP?
A
The acronym for daily progress note.
S: subjective
O: objective
A: assessment
P: Plan
