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Flashcards in Smith Lecture: OR Charting Deck (11)
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1
Q

What needs to be in preop note?

A
  • depends on hospital policy: simple statement updating PCP H&P stating that H&P is correct and there are no contraindication for surgery
  • May need to do full H&P with heart and lung exam
2
Q

What needs to be listed on consent form?

A
  • Procedure being done
    • do not use abbreviations, put in words that people can understand
  • Potential risks and complications
    • legal standard is to list probable complications (more than 50% of time)
3
Q

what might be a part of preop orders?

A
  • consent for surgery being performed
  • preop antibiotics
  • NPO midnight before procedure
  • labs to be done before procedure
4
Q

What goes into a brief postop note?

A

SAPPPPAHEMIC

  • surgeon
  • assistant surgeon
  • preop diagnosis
  • postop diagnosis
  • procedure
  • pathology (and cultures or specimens sent)
  • anesthesia (general or local)
  • hemostasis (tournique type, presure and time)
  • estimated blood loss
  • materials (any scres, plates, sutures, etc)
  • injectables (local or steroids)
  • condition (was pt stable at end of case?)
5
Q

what goes into a full operative note?

A
  • SAPPPPAHEMI and ….
  • positioning
  • sterile prep
  • tournique application
  • timeout
  • procedure detail
    • incision length and location, dissection, what was performed, irrigation, closure, dressings, etc
6
Q

what goes into post-op orders?

A

ADCVANDILMAX

Admit: where, to whom

Dx: status post op of ….

Condition: stable

Vitals

Activity: NWB, w/ crutches

Nursing: ice and elevate

Diet: regular

I+O: IV until taking PO fluids

Labs:

Meds:

Ancillary: PT?

X-ray:

7
Q

what goes into progress note?

A

SOAP note on a patient in the hospital (what you write after visiting them that day)

8
Q

what goes into discharge note?

A

discharge orders, f/u information

9
Q

hospital discharge summary

A

date of admit

date of discharge

principal diagnosis

secondary diagnosis

operative procedutres

consults

summary of stay

condition of pt upon discharge

discharge instructions

10
Q

orders for outpatient surgery

A

dressing instructions

WB status

activity instructions

xray

pain med

f/u instructions

durable medical equipment DME

11
Q
A