Surgery Overview Outline

Question 1

Questions

Answer 1

Answers

Question 2

Supplements that can cause bleeding problems

Answer 2

Gingko biloba; garlic; ginseng; fish oil (omega-3 fatty acids); Dong quai

Question 3

OTCs that can cause bleeding problems

Answer 3

Aspirin, Aleve, Advil, Motrin, Vitamin E

Question 4

Supplements that can have cardiovascular effects

Answer 4

Ephedra (causes HTN, palpitations, & tachycardia)
Garlic (causes HYPOtension)

Question 5

Supplements that can cause drug interactions

Answer 5

Echinacea, Goldenseal, Licorice, St. John’s Wort; Kava, Valerin

Question 6

Supplements that can have anesthetic effects

Answer 6

Valerian, St John’s Wort, Kava

Question 7

Required contents of signed consent

Answer 7

Procedure & location (Right TKR)
Alternative procedures that will be decided intra-operatively
Risks, benefits, and potential complications
Signatures of patient, surgeon, and whomever consented the person

Question 8

Post Procedure Note

Answer 8

Note written immediatelyafter surgery, including patient’s condition prior to transfer to PACU, allowing patient care providers to know immediate information pertaining to the surgical patient. This is a JCAHO requirement but does not replace the operative note.

Question 9

Operative Note

Answer 9

Legal document required within 24 hr of surgery; must be completed by physician and include “play-by-play”. Template for routine surgeries may be employed by doctors.

Question 10

Required components of admission order

Answer 10

Admit/Transfer
Diagnosis at admission
Vitals (how often)
Allergies
Nursing (Diet/IV)
Condition
Exercise
Labs
When to call

Question 11

Daily Progress Note

Answer 11

Use SOAP format. Check the following before morning rounds. On afternoon rounds, report any significant events. However, don’t wait for afternoon rounds to report something significant.

Question 12

Examined components during morning rounds

Answer 12

Appearance
Vital signs
Output
Input
Drains
Wound/Dressing/weight
Temperature
Examination

Question 13

ICU note timing

Answer 13

Before morning rounds. Thorough & systematic. Plan to spend at least 30 minutes per patient for your exam and note writing.

Question 14

Discharge Summary Contents

Answer 14

Summarizes:
Admitting diagnosis
Discharge Diagnosis
Diagnostic procedures
Therapy received
Clinical course
Prognosis
Discharge instructions (diet, activities, medications, follow-up).

Short stay form is completed for hospitalization

Question 15

Presenting on Rounds

Answer 15

Be concise. Never lie or hedge. Never whine. Be a team player. If you don’t know, “I do not know, but I will find out.”

Question 16

Round Presentation Contents

Answer 16

Patient name
Post-op day & procedure
Significant events in past 24 hr
Vitals/temp/24 hr output
ABX and day of ABX
Pertinent labs
Pertinent change in PE
Any complaints
PLAN!

Question 17

Timing of Admission H&P

Answer 17

within 24 hr of admission

Question 18

Informed Consent Timing

Answer 18

within 30 day of surgery; must be witnessed by someone NOT on surgical team

Question 19

Pre-Op H&P timing

Answer 19

within 30 days of surgery, updated on surgery day

Question 20

Post-op note timing

Answer 20

immediately after surgery

Question 21

Post-op orders timing

Answer 21

immediately after surgery

Question 22

Operative note timing

Answer 22

within 24 hr of surgery completion

Question 23

Progress note timing

Answer 23

daily by each service treating patient

Question 24

Order timing

Answer 24

daily

Question 25

Discharge summary timing

Answer 25

Handwritten form complete if stay less than 48 hr; dictated if > 48 hr

Question 26

Rules of Paperwork

Answer 26

PA should fill out all paperwork possible. Only paperwork legally obligated to surgeon = operative note. Everything requires time/date stamp.