Surgical Notes

Question 1

Pre-op H and P components?

Answer 1

• includes details about presenting condition: also establishes the acuity, urgency, or chronic nature of the problem
• questions will focus on specific disease and related organ system
• should include any documents that relate to specific condition as to limit repeating test
• include prior procedures and complications (DVT, prolonged bleeding, anesthesia problems)
  -Surgical hx
• family hx: bleeding disorders or anesthetic disorders
• complete ROS
• physical exam/vital signs
• impression
• plan:
  option besides surgical, brief description of the surgery and complications, informed consent (blood products), description of pre-op orders

Question 2

What are the components of informed consent?

Answer 2

• part of pre-op notes
• ethical and legal responsibility of providers
• contains 3 elements:
  provide adequate info
  is decision voluntary?
  pt’s decisional capacity
• includes:
  nature of tx
  risks
  benefits
  alternative
  opportunity for ?s

Question 3

What are part of the admission orders?

Answer 3

tells surgical floor what is needed for the pt

• admit
• dx
• conditions
• vital signs
• allergies
• nursing orders
• diet
• activity
• labs
• IV fluids
• studies
• meds

Question 4

What needs to be included in the operative report?

Answer 4

• document that details the surgical procedures
• stds for report are set by:
  AAAHC
  JCAHO
  requirements:
• indications for procedure
• a full description of procedure
• intra-op complications

Question 5

OR key elements?

Answer 5

• pt, date and time
• surgeon, assistant, anesthesiologist
• pre and post-op dx
• indications
• name of procedure
• procedure description:
  position
  prep and drape
  incision
  description of findings
  closure and dressings
  disposition and condition

Question 6

What are the components of the post-op note?

Answer 6

• written immediately after procedure
• physician assistant usually documents
• includes:
  date/time
  dx
  name of procedure
  surgeon/assistant
  type of anesthesia
  specimens
  EBL
  complications

Question 7

What are components of post-op orders?

Answer 7

• similar to admit orders
• more specific to operative procedure:
  drains
  incisions
  pain management
  N/V management
  DVT prophylaxis

Question 8

What is included in the daily progress note?

Answer 8

• rounding notes
• can be in SOAP format
• helps understand the pts progress
• add info from the nurse
• this is usually done 2x a day:
  morning rounds
  evening rounds

Question 9

What is included in d/c summary?

Answer 9

• synopsis of pt’s entire hosp stay
• usually is done the day of d/c

should include:

• admit date, admit dx
• d/c date, d/c dx
• date and type of surgery, procedure
• brief summary of pt’s H and P
• summary of hospital course
• pathology reports
• disposition