Surgical Documentation

Question 1

Preop note includes?

ASIDB

Answer 1

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

Question 2

Hospital Orders:

ADC VAANDIML

Answer 2

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

Question 3

Immediate PostOp Note includes?

PPPAAA OSPEU FCP

Answer 3

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

Question 4

PostOp Rounding notes contain?

Answer 4

SOAP

*do not include pathology u/l documented by preceptor

Question 5

Advanced Directives are?

Include?

Answer 5

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

Living Wills
Durable POA

Question 6

Living Will specifies?

Answer 6

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

Does NOT include w/drawl of nutrition or hydration

Question 7

POA specifies?

Answer 7

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

Question 8

DNR orders are rescinded when?

Answer 8

during surgery