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Flashcards in Surgical Notes Deck (16):
1

What major complications are we concerned about in the pre-op H&P

DVT
Prolonged bleeding history
Anesthesia problems

2

What is the impression of the pre-op H&P?

Diagnosis or assessment

3

Plan Part of Pre-op H&P

Options besides surgical
Brief description of surgery & complications
Informed consent
Description of pre-op orders

4

3 Elements of Informed Consent

Provide adequate information
Is the decision voluntary
Patient's decisional capacity

5

What does the informed consent include?

Nature of the treatment
Risk
Benefits
Alternative
Opportunity for questions

6

How to Write Admission Orders

ABC VANDALISM

7

Describe ABC VANDALISM

A: admit
B: because (diagnosis)
C: condition
V: vitals
A: allergies
N: nursing orders (showering, I/O, etc)
D: diet
A: activity (ad lib, bed rest)
L: labs
I: IV fluids
S: studies (US, CT, MRI)
M: medications

8

Requirements of an Operative Report

Indications for procedure
Full description of the procedure
Intra-operative complications

9

Key Elements of an Operative Report

Patient, date, & time
Surgeon, assistant, & anesthesiologist
Pre & Post-op diagnosis
Indications
Name of procedure
Procedure description

10

Parts of Procedure Description

Position
Prep & drape
Incision
Descriptions of findings
Closure & dressings
Disposition & condition

11

When is the Post-Op Note Written?

Immediately after the procedure

12

What is included in the post-op note?

Date/time
Diagnosis
Name of procedure
Surgeon/assistant
Type of anesthesia
Specimens
EBL
Complications

13

Post-Op Orders

Similar to admit orders
More specific to operative procedure
Drains
Incision
Pain management
N/V management
DVT prophylaxis

14

Daily Progress Notes

SOAP format
Helps to understand patients progress
Information from nurse

15

Discharge Summary

Synopsis of hospital stay
Done day of discharge

16

Discharge Summary Should Include

Admit date & diagnosis
Discharge date & diagnosis
Date & type of surgery/procedures
Brief summary of H&P
Summary of hospital course
Pathology reports
Disposition: discharge meds, FU instructions, diet/activity