Surgical Note

Question 1

Pre-OP H&P
1. Should include any documents that relate to the specific condition. Why?

2. Include prior what? 2

Answer 1

1. limit repeating test

2. procedures and complications

Question 2

Family Hx

Specifically what are we looking for? 2

Answer 2

1. Bleeding disorders

2. Anesthetic disorders

Question 3

Pre-Op H&P
What should the plan include?
4

Answer 3

1. Options besides surgical
2. Brief description of the surgery and complications
3. Informed consent
4. Description of pre-op orders

Question 4

Informed Consent

1. Part of what?
2. Contains 3 elements?

Answer 4

1. Part of the pre-op notes
2. Contains 3 elements
   - Provide adequate information
   - Is the decision voluntary
   - Patient’s decisional capacity

Question 5

INformed consent includes what? 5

Answer 5

1. Nature of the treatment
2. Risk
3. Benefits
4. Alternative
5. Opportunity for questions

Question 6

Admission Orders:
Tells the surgical floor what is needed for the patient
Remember “ABC VANDALISM”
12

Answer 6

1. Admit
2. Diagnosis (Because)
3. Condition
4. Vital signs
5. Allergies
6. Nursing orders
7. Diet
8. Activity
9. Labs
10. IV fluids
11. Studies
12. Medication

Question 7

Operative Report
1. Standards for the reports are set by: 2

2. Requirements? 3

Answer 7

1. • Accreditation Association for Ambulatory Health Care (AAAHC)
   • Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
2. • Indications for the procedure
   • A full description of the procedure
   • Intra-operative complications

Question 8

OR Key Elements

6

Answer 8

1. Patient, date, and time
2. Surgeon, assistant, anesthesiologist
3. Pre & Post-op diagnosis
4. Indications
5. Name of procedure
6. Procedure description

Question 9

Procedure description

6

Answer 9

1. Position
2. Prep and drape
3. Incision
4. Description of findings
5. Closure and dressings
6. Disposition and condition

Question 10

Post-Op Note
Written immediately after the procedure: Physician Assistant usually documents
Includes?

8

Answer 10

1. Date/Time
2. Diagnosis
3. Name of procedure
4. Surgeon/assistant
5. Type of anesthesia
6. Specimens
7. EBL
8. complications

Question 11

Post-Op Orders
Similar to admit orders
More specific to operative procedure?
5

Answer 11

1. Drains
2. Incision
3. Pain management
4. N/V management
5. DVT prophylaxis

Question 12

Daily Progress Note

This is usually done twice a day. When?

Answer 12

Morning rounds and evening rounds

Question 13

Discharge Summary
Synopsis of patient’s entire hospital stay
-Usually is done the day of discharge

Should include? 7

Answer 13

1. Admit date, admit diagnosis
2. Discharge date, discharge diagnosis
3. Date and type of surgery, procedure(s)
4. Brief summary of pt’s H&P
5. Summary of hospital course
6. Pathology reports
7. Disposition