Surgical Documentation for Gynecology
Gynecologic Surgical History
Age, gravida (number of pregnancies),para (number of deliveries).
Reason given by patient for seekingsurgical care.
History of Present Illness (HPI).
Describe the course ofthe patient's illness, including when it began, character ofthe symptoms; pain onset (gradual or rapid), character ofpain (constant, intermittent, cramping, radiating); otherfactors associated with pain (urination, eating, strenuousactivities); aggravating or relieving factors. Other relateddiseases; past diagnostic testing.
Past pregnancies, durations andoutcomes, preterm deliveries, operative deliveries.
Last menstrual period, length ofregular cycle.
Past Medical History (PMH).
Past medical problems,previous surgeries, hospitalizations, diabetes, hypertension, asthma, heart disease.
Cardiac medications, oral contraceptives,estrogen.
Medical problems in relatives.
Alcohol, smoking, drug usage, occupation.
Review of Systems (ROS):General:
Fever, fatigue, night sweats.
Headaches, masses, dizziness.
Cough, sputum, dyspnea.
Chest pain, extremity edema.
Vomiting, abdominal pain, melena(black tarry stools), hematochezia (bright red blood perrectum).
Dysuria, hematuria, discharge.
Easy bruising, bleeding tendencies.
Gynecologic Physical Examination
Temperature, respirations, heart rate, bloodpressure.
Pupils equally round and react to light and accommodation (PERRLA); extraocular movements intact(EOMI).
Jugular venous distention (JVD), thyromegaly,masses, lymphadenopathy.
Equal expansion, rales, breath sounds.
Regular rate and rhythm (RRR), first and secondheart sounds, murmurs.
Skin retractions, masses (mobile, fixed), erythema, axillary or supraclavicular node enlargement.
Scars, bowel sounds, masses,hepatosplenomegaly, guarding, rebound, costovertebralangle tenderness, hernias.
Urethral discharge, uterus, adnexa, ovaries, cervix.
Cyanosis, clubbing, edema.
Mental status, strength, tendon reflexes,sensory testing.
Electrolytes, glucose, liver function tests, INR/PTT, CBC with differential; X-rays, ECG (if>35 yrs or cardiovascular disease), urinalysis.
Assessment and Plan:
Assign a number to each problem. Discuss each problem, and describe surgical plans foreach numbered problem, including preoperative testing,