Surgical Documentation S. E.

Wilson, MD

Surgical History and Physical Examination

Identifying Data:
Patient's name, age, race, sex; referring physician.

Chief Com liant:

!eason given by patient for seeking surgical care and the duration of the symptom.

History of Present Illness "HPI#:

Describe the course of the patient's illness, including when it began, character of the symptoms; ain onset (gradual or rapid , precise character of pain (constant, intermittent, cramping, stabbing, radiating ; other factors associated with pain (defecation, urination, eating, strenuous activities ; location where the symptoms began; aggravating or relieving factors. $omiting (color, character, blood, coffee!ground emesis, fre"uency, associated pain . Change in %o&el ha%its; rectal 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#:

Previous operations and indications; dates and types of procedures; serious in#uries, hospitali$ations; diabetes, hypertension, peptic ulcer disease, asthma, heart disease; hernia, gallstones.

Medications:
%spirin, anticoagulants, hypertensive and cardiac medications, diuretics.

'llergies:
Penicillin, codeine, iodine.

(amily History:
&edical problems in relatives. 'amily history of colon cancer, cardiovascular disease.

Social History:
%lcohol, smoking, drug usage, occupation, daily activity.

!e)ie& of Systems "!*S#: +eneral:

(eight gain or loss; loss of appetite, fever, fatigue, night sweats. %ctivity level.

HEE,-:
)eadaches, sei$ures, sore throat, masses, dentures.

!es iratory:
*ough, sputum, hemoptysis, dyspnea on exertion, ability to walk up flight of stairs.

Cardio)ascular:
*hest pain, orthopnea, claudication, extremity edema.

+astrointestinal:
Dysphagia, vomiting, abdominal pain, hematemesis, melena (black tarry stools , hematoche$ia (bright red blood per rectum , constipation, change in bowel habits; hernia, hemorrhoids, gallstones.

+enitourinary:
Dysuria, hesitancy, hematuria, discharge; impotence, prostate problems, urinary fre"uency.

+ynecological:
+ast menstrual period, gravida, para, abortions, length of regular cycle and periods, birth control.

S.in:
,asy bruising, bleeding tendencies.

,eurological:
-troke, transient ischemic attacks, weakness.

Surgical Physical Examination

+eneral a $ital Signs:
1emperature, respirations, heart rate, blood pressure, weight.

earance:

.ote whether the patient looks /ill,0 well, or malnourished.

Eyes:
Pupils e"ually round and react to light (P,22+ ; extraocular movements intact (,3&4 .

,ec.:
5ugular venous distention (56D , thyromegaly,masses, bruits; lymphadenopathy; trachea midline.

Chest:
,"ual expansion, dullness to percussion; rales,rhonchi, breath sounds.

Heart:
2egular rate and rhythm (222 , first and second heart sounds; murmurs (grade 7!8 , pulses (graded 9:; .

/reast:
-kin retractions, erythema, tenderness, masses (mobile, fixed , nipple

discharge, axillary or supraclavicular node enlargement.

'%domen:
*ontour (flat, scaphoid, obese, distended ,scars, bowel sounds, bruits, tenderness, masses, liver span; splenomegaly, guarding, rebound, percussion note (dull, tympanic , pulsatile masses, costovertebral angle tenderness (*6%1 , abdominal hernias.

+enitourinary:
4nguinal hernias, testicles, varicoceles; urethral discharge, varicocele.

Extremities:
-kin condition, edema (grade 7 ! <; ; cyanosis, clubbing, pulses (radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis; simultaneous palpation of radial and femoral pulses . =rading of pulses> 9 ? absent; 7; weak; :; normal; @; very strong (arterial dilation .

!ectal Exam:
&asses, tenderness, hemorrhoids, prostate masses; bimanual palpation, guaiac test for occult blood.

,eurological:
&ental status, cranial nerves, gait,strength (graded 9 ! A ; tendon reflexes, sensory testing.

0a%oratory E)aluation:
,lectrolytes (sodium, potassium, bicarbonate, chloride, BC., creatinine , glucose, liver function tests, 4.2DP11, *B* with differential; urine analysis. E!rays, ,*= (if older than @A yrs or cardiovascular disease ,

'ssessment "Im ression#:

%ssign a number to each problem and discuss each problem. Begin with most important problem and rank in order.

Plan:
Discuss surgical plans for each numbered problem, including preoperative testing, laboratory studies, medications, antibiotics, endoscopy.

Preo erati)e Pre aration of the Surgical Patient

2eview the patient's history and physical examination, and write a reo erati)e note assessing the patient's overall condition and operative risk.

Preo erati)e la%oratory e)aluation:

,lectrolytes, BC., creatinine, 4.2DP11, *B*, platelet count, C%, %B=, pulmonary function test. *hest x!ray (F@A yrs old , ,G= (if older then @A yrs old or if cardiovascular disease . 1ype and cross for an appropriate number of units of blood. .o screening laboratory tests are re"uired in the healthy patient.

S.in re aration:
Patient to shower and scrub the operative site with germicidal soap ()ibiclens on the night before surgery. 3n the day of surgery, hair should be removed with an electric clipper or shaved #ust prior to operation.

Pro hylactic anti%iotics or endocarditis ro hylaxis if indicated. Preo erati)e incenti)e s irometry
on the evening prior to surgery may be indicated for patients with pulmonary disease.

-hrom%oem%olic
prophylaxis should be provided for selected, high!risk patients.

Diet:
.P3 after midnight.

I$ and monitoring lines:

%t least one 7H!gauge 46 for initiation of anesthesia. %rterial catheter and pulmonary artery catheters (-wan!=an$ if indicated. Patient to void on call to operating room.

Medications.
Preoperative sedation as ordered by anesthesiologist. &aintenance medications to be given the morning of surgery with a sip of water. Diabetics should receive one half of their usual %& insulin dose, and an insulin drip should be initiated with hourly glucose monitoring.

/o&el re aration
Bowel preparation is re"uired for upper or lower =4 tract procedures. 'nti%iotic Pre aration for Colonic Surgery Mechanical Pre : Day 7> *lear li"uid diet, laxative (milk of magnesia @9 cc or magnesium citrate :A9 cc , tap water or 'leet enemas until clear. Day :> *lear li"uid diet, .P3, laxative. Day @> 3peration. Whole +ut 0a)age: Polyethylene glycol electrolyte solution (=o+ytely . Day 7> : liters P3 or per nasogastric tube over A hours. *lear li"uid diet. Day :> 3peration. *ral 'nti%iotic Pre > 3ne day prior to surgery, after mechanical or whole gut lavage, give neomycin 7 gm and erythromycin :A9 mg at 7 p.m., : p.m., 77 p.m.

Preo erati)e I$ anti%iotics:

4nitiate preoperatively and give one dose during operation and one dose of antibiotic postoperatively. *efotetan (*efotan , 7 gm 46 "7:h, for bowel flora, or cefa$olin (%ncef , 7 gm 46PB "Hh x @ doses, for clean procedures.

'nticoagulants:
Discontinue *oumadin A days preop and check P1; stop 46 heparin 8 hours prior to surgery. 'dmitting and Preo erati)e *rders

'dmit to: (ard, 4*C, or preoperative room. Diagnosis: 4ntended operation and indication. Condition: -table $ital Signs:
're"uency of vital signs; input and output recording; neurological or vascular checks. .otify physician if blood pressure IJ9D89, F789D779; pulse F779; pulse I89; temperature F797.A; urine output I@A ccDh for F: hours; respiratory rate F@9. 'cti)ity: Bed rest or ambulation; bathroom privileges. 'llergies: .o known allergies Diet: .P3 I$ *rders: DA 7D: .- at 799 ccDhour. *xygen: 8 +Dmin by nasal canula. Drains: 'oley catheter to closed drainage. .asogastric tube at low intermittent suction. 3ther drains, tubes, dressing changes. 3rders for

irrigation of tubes.

Medications:
%ntibiotics to be initiated immediately preoperatively; additional dose during operation and 7 dose of antibiotic postoperatively. *efotetan (*efotan , 7 gm 46 "7:h, for bowel flora, or cefa$olin (%ncef 7 gm 46PB "Hh x @ doses; for clean procedures.

0a%s and S ecial 12!ays:

,lectrolytes, BC., creatinine, 4.2DP11, *B*, platelet count, C%, %B=, pulmonary function tests. *hest x!ray (if F@A yrs old , ,G= (if older then @A yrs old or if cardiovascular disease . 1ype and cross for an appropriate number of units of blood.

Preo erati)e ,ote Preo erati)e Diagnosis: Procedure Planned: -y e of 'nesthesia Planned: 0a%oratory Data: ,lectrolytes, BC., creatinine, *B*, 4.2DP11, C%, ,G=,
chest x!ray; type and screen for blood or cross match if indicated; liver function tests, %B=. !is. (actors: *ardiovascular, pulmonary, hepatic, renal, coagulopathic, nutritional risk factors.

'merican Surgical 'ssociation "'S'# grading of surgical ris.:

7? normal; :? mild systemic disease; @? severe systemic disease; <? disease with ma#or threat to life; A? not expected to survive.

Consent:
Document explanation to patient of risks and benefits of the procedure and alternative treatments. Document patient's or guardian's informed consent and understanding of the procedure. 3btain signed consent form.

'llergies: Ma3or Medical Pro%lems: Medications: S ecial !e4uirements: -igned blood transfusion consent form;
documentation that breast procedure patients have been given an information brochure.

/rief * erati)e ,ote

1his note should be written in chart immediately after the surgical procedure. Date of the Procedure: Preo erati)e Diagnosis: Posto erati)e Diagnosis: Procedure: * erati)e (indings: ,ames of Surgeon and 'ssistants: 'nesthesia: =eneral endotracheal, spinal, epidural, regional or local. Estimated /lood 0oss "E/0#: (luids and /lood Products 'dministered During Procedure: 5rine out ut: S ecimens: Pathology specimens, cultures, blood samples. Intrao erati)e 12rays: Drains: Condition of Patient: -table

* erati)e !e ort
1his full report should be dictated at the conclusion of the surgical procedure. Identifying Data: .ame of patient, medical record number; name of dictating physician, date of dictation. 'ttending Surgeon and Ser)ice: Date of Procedure: Preo erati)e Diagnosis: Posto erati)e Diagnosis: Procedure Performed: ,ames of Surgeon and 'ssistants: -y e of 'nesthesia 5sed: Estimated /lood 0oss "E/0#: (luid and /lood Products 'dministered During * eration: S ecimens: Pathology, cultures, blood samples. Drains and -u%es Placed: Com lications: Consultations Intrao erati)ely: Indications for Surgery: Brief history of patient and indications for surgery. (indings: Describe gross findings and fro$en section results relayed to operating room. Descri tion of * eration: Position of patient; skin prep and draping; location and types of incisions; details of procedure from beginning to end, including description of surgical findings, both normal and abnormal. 4ntraoperative studies or x!rays; hemostatic and closure techni"ues; dressings applied. .eedle and sponge counts as reported by operative nurse. PatientKs condition and disposition. -end copies of report to surgeons and referring physicians.

Posto erati)e Chec.

% postoperative check should %e com leted on the e)ening after surgery . 1his check is similar to a daily progress note.

E1'MP0E P*S-*PE!'-I$E CHEC6

Date 7 -ime Posto erati)e Chec. Su%3ecti)e ; note any patient complaints, and note the ade"uacy pain relief. *%3ecti)e 8 +eneral a earance $itals ; maximum temperature in the last :< hours (1 max , current temperature, pulse, respiratory rate, blood pressure 5rine out ut > Physical Examination Chest 9 0ungs '%domen Wound Examination > the wound should be examine for excessive drainage or bleeding, skin necrosis, condition of drain Drainage )olume ; note the volume and characteristics of drainage from 5ackson Pratt drains or other drains 0a%s Post operative hematocrite value and others lab 'ssesment and Plans %sses the patient overall condition and status of wound *omment on abnormal labs Discuss treatment Discharge plan

Posto erati)e *rders

-ransfer: 'rom recovery room to surgical ward when stable. $ital Signs: "<h, 4L3 "<h x :<h. 'cti)ity: Bed rest; ambulate in 8!H hours if appropriate. 4ncentive spirometer "7h while awake. Diet: .P3 x Hh, then sips of water. %dvance from clear li"uids to regular diet as tolerated. I$ (luids: 46 DA +2 or DA 7D: .- at 7:A ccDh (G*+, :9 m,"D+ if indicated , 'oley to gravity. Medications: *efa$olin (%ncef 7 gm 46PB "Hh x @ doses; if indicated for prophylaxis in clean cases *! *efotetan (*efotan 7 gm 46 "7:h x : doses for clean contaminated cases. &eperidine (Demerol A9 mg 46D4& "@!<h prn pain )ydroxy$ine (6istaril :A!A9 mg 46D4& "@!<h prn nausea *! Prochlorpera$ine (*ompa$ine 79 mg 46D4& "<!8h prn nausea or suppository " <h prn. 0a%oratory E)aluation: *B*, -&%M, chest x!ray in %& if indicated.

Posto erati)e Surgical Management

Posto erati)e day num%er : 7. %ssess the patientKs level of pain, lungs, cardiac status, flatulence, and bowel movement. ,xamine for distension, tenderness, bowel sounds; wound drainage, bleeding from incision. :. Discontinue 46 infusion when taking ade"uate P3 fluids. Discontinue 'oley catheter, and use in!and out catheteri$ation for urinary retention. @. %mbulate as tolerated; incentive spirometer, hematocrit and hemoglobin. <. %cetaminophenDcodeine (1ylenol N@ 7!: P3 "<!8h prn pain. A. *olace 799 mg P3 bid. 8. *onsider prophylaxis for deep vein thrombosis. Posto erati)e day num%er ; 7. 4f passing gas or if bowel movement, advance to regular diet unless bowel resection. :. +axatives> Dulcolax suppository prn or 'leet enema prn or milk of magnesia, @9 cc P3 prn constipation. Posto erati)e day num%er <2= 7. *heck pathology report. :. 2emove staples and place steri!strips. @. *onsider discharge home on appropriate medications; follow up in 7!: weeks for removal of sutures. <. (rite discharge orders (including prescriptions in %&; arrange A. for home health care if indicated. Dictate discharge summary and send copy to surgeon and referring physician.

Surgical Progress ,ote -urgical progress notes are written in /-3%P0 format. S5!+IC'0 P!*+!ESS ,*-E Date 1ime Post 3perative Day .umber . . . . Pro%lem 0ist %ntibiotic day number )yperalimentation day number if applicable +ist each surgical problem separately ( e" ; status post appendectomy, hypokalemia Su%3ecti)e ; Describe how the patient feels in the patient onwards, and give the observation about the patient 4ndicate any new patient complaint .ote the ade"uacy of pain relief %nd passing of flatus and bowel movement 1ype of food the patient is tolerating ( e" > nothing, +i"uids, regular diet *%3ecti)e > $ital Signs > maximum temperature over the past :< hours, current temperature, vital signs Inta.e and out ut > 6olume of oral and intravenous fluids, volume of urine, stools, drains and nasogastric output Physical Examination > =eneral %ppearance > alert, %mbulating Heart > 2egular )eart anf 2hytm Chest ; *lear to auscultation '%domen > Bowel sound present, soft, non tender Wound Condition > comment of the wound condition, clean and dry, good granulation, serosanguines drainage, granulation tissue, erythema, condition of suture, dehiscence, 'mount and color of drainage 0a% 9 x ray, others examination 2esult > 'ssesment and Plan > ,valuate each number problem separately .ote the patient general condition ( e" ; improving , pertinent development ( e" > "dvance diet to regular, chest x ray 'or each numbered problem, discuss any additional orders and plans for discharge and transfer

Procedure ,ote
% procedure note should be written in the chart when a procedure is performed. Procedure notes are brief operative notes.

Discharge ,ote
1he discharge note should be written in the patientKs chart prior to discharge. DISCH'!+E ,*-E

Date Times Diagnosis Treatment

Breafly describe treatment provided during hospitalization, including surgical procedures and antibiotic therapy

Studies Performed ; ECG, CT Scan ischarge !edication " #ollo$%up &rrangement ;

Discharge Summary
Patient>s ,ame : Chart ,um%er : Date of 'dmission : Date of Discharge : 'dmitting Diagnosis : Discharge Diagnosis : ,ame of 'ttending or Ward Ser)ice: Surgical Procedures : Diagnostic -ests : In)asi)e Procedures : /rief History and Pertinent Physic Exam and 0a%oratory Data: Describe the course of the patientKs disease up to the time the patient came to the hospital, and describe the physical exam and pertinent laboratory data on admission. Hos ital Course: Briefly describe the course of the patient's illness while in the hospital, including evaluation, operation, outcome of the operation, and medications given while in the hospital. Discharged Condition: Describe improvement or deterioration of the patientKs condition. Dis osition: Describe the situation to which the patient will be discharged (home, nursing home and the person who will provide care. Discharged Medications: +ist medications and instructions and write prescriptions. Discharged Instructions and (ollo&2u Care: Date of return for follow!up care at clinic; diet, exercise instructions. Pro%lem 0ist: +ist all active and past problems. Co ies: -end copies to attending physician, clinic, consultants and referring physician.

Prescri tion Writing

PatientKs name> Date> Drug name, dosage form, dose, route, fre"uency (include concentration for oral li"uids or mg strength for oral solids >

Amoxicillin 125mg/5mL 5 mL PO tid Quantity to dispense : mL for oral liquids, # of oral solids Refills: If appropriate Signature