SURGICAL DOCUMENTATION

SURGICAL HISTORY AND PHYSICAL EXAMINATION Identifying Data: patient's name, age, race, sex; referring physician. Chief Complaint: Reason given by patient for seeking surgical care; place reason in "quotation marks." History of Present Illness (HPI): Describe the course of the patient's illness, including when it began, character of the symptoms; pain onset (gradual or rapid), precise character of pain (constant, intermittent); other factors associated with pain (defecation, urination, eating, strenuous activities); location where the symptoms began; aggravating or alleviating factors. Vomiting (characteristics, appearance, frequency, associated pain). Change in bowel habits; bleeding, character of blood, (clots, bright or dark red), trauma; recent weight loss or anorexia; other related diseases; past diagnostic testing. Past Medical History (PMH): past diseases. All previous surgeries and indications; dates and types of procedures; serious injuries, hospitalizations; significant medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma, myocardial infarction; hernia, gallstones. Medications: Allergies: Penicillin: Codeine? Family History: Medical problems in relatives. Family history of colonic polyposis, carcinomas, multiple endocrine neoplasia (MEN syndrome). Social History: Alcohol, smoking, drug usage. Review, of Systems (ROS): General: Weight gain or loss; appetite loss, fever, fatigue, night sweats. Head: Headaches, seizures. Eyes: Visual changes, diplopia, eye pain. Mouth & Throat: Dental disease, hoarseness, sore throat, pain, masses. Respiratory: Cough, shortness of breath, sputum. Cardiovascular: Chest pain, orthopnea, dyspnea on exertion, claudication, extremity edema. Gastrointestinal: Dysphasia, abdominal pain, nausea, vomiting, hematemesis, melena (black tarry stools), hematochezia (bright red blood per rectum), constipation, bloody stool, change in bowel habit; hernia, hemorrhoids, gallstones. Genitourinary: Dysuria, frequency, hesitancy, hematuria, polyuria, discharge; impotence, prostate problems. Gynecological: Last menstrual period, breast masses. Skin: Easy bruising, bleeding tendencies. Lymphatics: Lymphadenopathy. SURGICAL PHYSICAL EXAMINATION Vital Signs: Temperature, heart rate, respirations, blood pressure, weight. Head, Eyes, Ears, Nose, Throat (HEENT): Eyes: Pupils equally round and react to light and accommodation (PERRLA): extraocular movements intact (EOMI); Neck: Jugular venous distention (JVD), thyromegaly, masses, bruits; lymph nodes. Chest: Equal expansion; rhonchi, crackles, breath sounds. Heart: Regular rate & rhythm (RRR), first & second heart sounds; murmurs (grade 1-6), pulses (graded 0-2+). Breast: Retractions, tenderness, lumps, nipple discharge, dimpling, gynecomastia; axillary nodes. Abdomen: contour (flat, scaphoid, obese, distended); scars, bowel sounds, tenderness,

Chest X-ray. simultaneous palpation of radial and femoral pulses). rebound. respirations. Rectal Exam: Sphincter tone. varicoceles. blood pressure. urine analysis (UA). laboratory studies. blood samples. UA. costovertebral angle tenderness (CVAT). conditions of drains. Homan's sign (dorsiflexion of foot elicits calf tenderness). POSTOPERATIVE NOTE Subjective: Mental status & patient's subjective condition. Plan: Describe surgical plans including preoperative testing. liver span. Risk Factors: Cardiovascular. bicarbonate. gait. creatinine. BUN. PREOPERATIVE NOTE Preoperative Diagnosis: Procedure Planned: Type of Anesthesia Planned: Laboratory Data: Electrolytes. cyanosis. Vital Signs: Temperature. nutritional risk factors. liver function tests. type and screen for blood or cross match if indicated. Genitourinary: External lesions. scrotum. percussion note (tympanic). guaiac test for occult blood. CBC. testicles. CBC. Extremities: Edema (grade 1-4+). PT/PTT. inguinal masses. renal. Allergies: Major Medical Problems: Medications: BRIEF OPERATIVE NOTE (Written immediately after the procedure) Date of the Procedure: Preoperative Diagnosis: Postoperative Diagnosis: Procedure: Names of Surgeon and Assistant: Anesthesia: Estimated Blood Loss (EBL): Fluids and Blood Products Administered During Procedure: Specimens: Pathology specimens. prostate masses. potassium. ECG (if older than 35 yrs or history of cardiovascular disease). Assessment (Impression): Assign a number to each problem and discuss each problem separately. Xrays. guarding. Labs: Electrolytes (sodium. dorsalis pedis. strength (graded 0-5). fissures. bruits. BUN. edema (CCE). clubbing. Physical Exam: Chest and lungs. popliteal. chloride. masses. PT/PTT. Labs: . posterior tibial. cultures. hemorrhoids. characteristics and volume of output of drains. pulses (radial ulnar. hepatic. masses. EKG. femoral. liver function tests. splenomegaly. Neurological: Mental status. coagulopathic. ABG. pulmonary.organomegaly. hernias. antibiotics. inspection of wound and surgical dressings. and document patient's informed consent or guardian's consent and understanding of procedure. creatinine). medications. deep tendon reflexes. pulse. pain control. Consent: Document explanation to patient of risk and benefits of procedure.

include evaluation.Impression: Plan: PROBLEM-ORIENTED PROGRESS NOTE Problem List: Postoperative day number. Problem List: List all active and past problems. treatment. . granulation tissue. Objective: Vital signs. Discuss changes in drug regimen or plans for discharge or transfer. Discharge Condition: Describe improvement or deterioration in patient's condition. condition of sutures. Address each numbered problem daily in progress note. DISCHARGE SUMMARY Patient's Name: Chart Number: Date of Admission: Date of Discharge: Admitting Diagnosis: Discharge Diagnosis: Attending or Ward Team: Surgical Procedures. dehiscence. laboratory data. erythema. and person who will take care of patient. Subjective: Write how the patient feels in the patient's own words. Discharged Instructions & Follow-up Care: Date of return for follow-up care at clinic. Invasive Procedures: Brief History & Pertinent Physical Examination & Laboratory Data: Describe the course of the patient's disease up until the patient came to the hospital including physical exam & laboratory data. nursing home). exercise. Hospital day number. Discuss conclusions of consultants. purulent drainage. Assessment: Evaluate each numbered problem separately. outcome of treatment. Condition of dressings. clinic. surgical plans. List each surgical problem separately (status postappendectomy. and give observations about the patient. and medications given while in the hospital. discuss any additional orders. hyperalimentation day number. Amount and color of drainage. antibiotic day number if applicable. diet. hypokalemia). Discharged Medications: List medications and instructions. Disposition: Describe the situation to which the patient will be discharged (home. physical exam for each system. Plan: For each numbered problem. consultants and referring physician. thorough examination and description of wound. Copies: Send copies to attending physician. Diagnostic Tests. Hospital Course: Describe the course of the patient's illness while in the hospital.

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