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Flashcards in Surgical Notes Deck (16)
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1
Q

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

A

DVT
Prolonged bleeding history
Anesthesia problems

2
Q

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

A

Diagnosis or assessment

3
Q

Plan Part of Pre-op H&P

A

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

4
Q

3 Elements of Informed Consent

A

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

5
Q

What does the informed consent include?

A
Nature of the treatment
Risk
Benefits
Alternative
Opportunity for questions
6
Q

How to Write Admission Orders

A

ABC VANDALISM

7
Q

Describe ABC VANDALISM

A
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
Q

Requirements of an Operative Report

A

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

9
Q

Key Elements of an Operative Report

A
Patient, date, & time
Surgeon, assistant, & anesthesiologist
Pre & Post-op diagnosis
Indications
Name of procedure
Procedure description
10
Q

Parts of Procedure Description

A
Position
Prep & drape
Incision
Descriptions of findings
Closure & dressings
Disposition & condition
11
Q

When is the Post-Op Note Written?

A

Immediately after the procedure

12
Q

What is included in the post-op note?

A
Date/time
Diagnosis
Name of procedure
Surgeon/assistant
Type of anesthesia
Specimens
EBL
Complications
13
Q

Post-Op Orders

A
Similar to admit orders
More specific to operative procedure
Drains
Incision
Pain management
N/V management
DVT prophylaxis
14
Q

Daily Progress Notes

A

SOAP format
Helps to understand patients progress
Information from nurse

15
Q

Discharge Summary

A

Synopsis of hospital stay

Done day of discharge

16
Q

Discharge Summary Should Include

A
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