What needs to be in preop note?
- 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
What needs to be listed on consent form?
- 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)
what might be a part of preop orders?
- consent for surgery being performed
- preop antibiotics
- NPO midnight before procedure
- labs to be done before procedure
What goes into a brief postop note?
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?)
what goes into a full operative note?
- SAPPPPAHEMI and ….
- positioning
- sterile prep
- tournique application
- timeout
- procedure detail
- incision length and location, dissection, what was performed, irrigation, closure, dressings, etc
what goes into post-op orders?
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:
what goes into progress note?
SOAP note on a patient in the hospital (what you write after visiting them that day)
what goes into discharge note?
discharge orders, f/u information
hospital discharge summary
date of admit
date of discharge
principal diagnosis
secondary diagnosis
operative procedutres
consults
summary of stay
condition of pt upon discharge
discharge instructions
orders for outpatient surgery
dressing instructions
WB status
activity instructions
xray
pain med
f/u instructions
durable medical equipment DME
