TERMS Flashcards
pre-op?
before
intra-op?
during
post-op?
after
peri-op?
around
surgical class?
healthy, least risk
class 1
surgical class?
smoker, systemic disease
class 2
surgical class?
severe systemic disease but is controlled
class 3
surgical class?
patient with severe systemic disease that is constant threat to life (hepato-renal failure)
class 4
surgical class?
not expected to survive with or without surgery
class 5
surgical chartings
subjective, objective, assessment, plan of action?
SOAP note
surgical chartings
written on day of surgery, always followed with any physician orders that should be done before surgery
last review of paperwork before surgery, note changes
should include-surgeon name, pre-op diagnosis, planned procedure, consent form signed, medical clearance, vitals, labs,chest radiographs
pre-operative note
surgical chartings
what you are doing to prep for surgery
preadmission testing
NPO, IV fluids, prophylactic ABX, surgical site prep
pre-op orders
surgical chartings
VANDILMAX (vitals, activities, nursing, diet, I/Os, labs, meds, ancillary, x-ray)
post-op orders
surgical chartings
summation of the operation, pertinent post-op care for patient
SAPPA HEMI
- surgeon
- assistants
- preop diagnosis
- postop diagnosis
- procedure
- anesthesia
- hemostasis
- estimated blood loss
- materials
- injectables
post-op note
surgical chartings
always done if patient is not admitted with instructions?
discharging the patient
