Surgical Notes Flashcards
What major complications are we concerned about in the pre-op H&P
DVT
Prolonged bleeding history
Anesthesia problems
What is the impression of the pre-op H&P?
Diagnosis or assessment
Plan Part of Pre-op H&P
Options besides surgical
Brief description of surgery & complications
Informed consent
Description of pre-op orders
3 Elements of Informed Consent
Provide adequate information
Is the decision voluntary
Patient’s decisional capacity
What does the informed consent include?
Nature of the treatment Risk Benefits Alternative Opportunity for questions
How to Write Admission Orders
ABC VANDALISM
Describe ABC VANDALISM
A: admit B: because (diagnosis) C: condition V: vitals A: allergies N: nursing orders (showering, I/O, etc) D: diet A: activity (ad lib, bed rest) L: labs I: IV fluids S: studies (US, CT, MRI) M: medications
Requirements of an Operative Report
Indications for procedure
Full description of the procedure
Intra-operative complications
Key Elements of an Operative Report
Patient, date, & time Surgeon, assistant, & anesthesiologist Pre & Post-op diagnosis Indications Name of procedure Procedure description
Parts of Procedure Description
Position Prep & drape Incision Descriptions of findings Closure & dressings Disposition & condition
When is the Post-Op Note Written?
Immediately after the procedure
What is included in the post-op note?
Date/time Diagnosis Name of procedure Surgeon/assistant Type of anesthesia Specimens EBL Complications
Post-Op Orders
Similar to admit orders More specific to operative procedure Drains Incision Pain management N/V management DVT prophylaxis
Daily Progress Notes
SOAP format
Helps to understand patients progress
Information from nurse
Discharge Summary
Synopsis of hospital stay
Done day of discharge
