Sullivan Chapter 8 - Documenting Daily Rounds Flashcards
What kind of note is frequently used to record information gathered in a daily visit?
SOAP note
The H&P is due within how many hours of hospitalization?
48 hours
What types of things should the daily SOAP note include?
1) Focus on changes
2) Presence or resolution of symptoms from admission
3) Pertinent positives and negatives
4) General assessment
5) Abnormal vitals
6) Heart and lungs as well as pertinent systems
7) Review of all test results
8) Patient condition
9) Plan with rationale
When assessing a post op patient how do you label the note to indicate the day?
POD (post op day)
What is the most common post-operative complication?
Fever
What are five causes of fever in the post-op patient?
1) Respiratory
2) Wound
3) UTI
4) Thromboembolic event
5) ADR (adverse drug reaction)
What two systems should be evaluated on every post-op patient?
Respiratory and cardovascular
What other system should be evaluated?
Derm or the surgical site
An order stays in effect until?
It is stopped or another order replaces it
What should be evaluated any time a change is made in the patient’s management?
The patient’s response to the change
What must be documented for every patient undergoing a surgical procedure?
A full operative report
What are the basic components of the op note?
1) Date of procedure
2) Name of procedure
3) Reason for the procedure
4) Surgeon
5) Assistants (if any)
6) Anesthesia (type and provider)
7) Preoperative DX
8) Postoperative DX
9) Description of procedure
10) Complications
11) Disposition
What is the name of the note that documents how a procedure was done and the patient’s response?
Procedural note
What is the name of the note used to document an obstetrical admission?
Delivery note
Who is responsible for obtaining consent for a procedure?
The person who will be performing the procedure
