Surgical Documentation Flashcards Preview

Q4 EM Surg > Surgical Documentation > Flashcards

Flashcards in Surgical Documentation Deck (8):
1

Preop note includes?
ASIDB

Admit/consult notes
Summary of relevant studies (lab, imaging)
Informed consent
Diet status
Blood product needs

2

Hospital Orders:
ADC VAANDIML

Admit
Dx
Condition
Vitals
Allergies
Activity
Nursing orders
Diet
IV fluids
Meds (home and hospital)
Labs

3

Immediate PostOp Note includes?
PPPAAA OSPEU FCP

Preop dx
Postop dx
Procedure
Attending
Assistants
Anesthesia type
Operative findings
Specimens removed
Pack/Drain/Catheters
Estimated blood loss
Urine output
Fluids given (incl blood, abx)
Complications
Pt disposition/condition

4

PostOp Rounding notes contain?

SOAP
*do not include pathology u/l documented by preceptor

5

Advanced Directives are?

Include?

Specific health care instructions in event pt can't communicate their decisions

Living Wills
Durable POA

6

Living Will specifies?

w/drawl of tx if terminally ill and can no longer make decisions

Does NOT include w/drawl of nutrition or hydration

7

POA specifies?

Legal surrogate to make health care decisions for the pt if they are not able to

8

DNR orders are rescinded when?

during surgery