Chapter 1 / Introduction 9
What should you do when you are scrubbed and someone is tying a suture?
Why always wipe the Betadine® (povidone-iodine) off your patient at the end of the procedure?
SURGICAL NOTES
Ask the scrub nurse for a pair of suture scissors, so you are ready if you are asked to cut the sutures
Betadine® can become very irritating and itchy
HISTORY AND PHYSICAL REPORT
The history and physical examination report, better known as the H & P, can make the difference between life and death. You should take this responsibility very seriously. Fatal errors can be made in the H & P, including the incorrect diagnosis, the wrong side, the wrong medications, the wrong allergies, and the wrong past surgical history. Operative reports of the patient’s past surgical procedures are invaluable! The surgical H & P needs to be both accurate and concise. To save space, use for a negative sign/symptom and for a positive sign/symptom.
What are the two words |
1. |
Guaiac |
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most commonly misspelled |
2. |
Abscess |
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in a surgical history note? |
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Favorite Trick Questions |
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What is the most common |
Foley catheter |
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intra-operative bladder |
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“tumor”? |
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Describe a stool with melena.
Is amylase part of Ranson’s criteria?
Can a patient in shock have “STABLE” vital signs?
What is the most commonly pimped, yet the rarest, cause of pancreatitis?
Where can you go to obtain an abdominal CT scan on a 600-pound, morbidly obese patient?
Melenic—not melanotic
Amylase is NOT part of Ranson’s criteria!
Yes—stable vital signs are any vital signs that are not changing! Always say “normal” vital signs, not “stable!”
Pancreatitis from a scorpion bite (scorpion found on island of Trinidad)
The ZOO (used in the past, but now rare due to liability)
10 Section I / Overview and Background Surgical Information
Example H & P (very brief—for illustrative purposes only—see below or next section for abbreviation key):
Mr. Smith is a 22-year-old African American man who was in his normal state of excellent health until he noted the onset of periumbilical pain 1 day prior to admission. This pain was followed 4 hours later by pain in his right lower quadrant that any movement exacerbated. vomiting, anorexia. fever, urinary tract symptoms, change in bowel habits, constipation, BRBPR, hematemesis, or diarrhea.
Medications:
Allergies:
PMH:
PSH:
SH:
FH:
ROS:
Physical Exam:
LABS:
X-RAYS:
ASSESSMENT:
Plan:
Wilson Tyler cc III/
NKDA no known drug allergies; PMH past medical history; PSH past surgical history; SH social history; FH family history; ROS review of systems; V/S vital signs; ncat normocephalic atraumatic; tms tympanic membranes; cor heart; m, r, g murmur, rub, gallop; NSR normal sinus rhythm; b/l bilateral; bs bowel sounds; ext extremity; nt nontender; c, c, e cyanosis, clubbing, or erythema; wnl within normal limits; cc III clinical clerk, third year
Chapter 1 / Introduction 11
PREOP NOTE
The preop note is written in the progress notes the day before the
operation |
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Example: |
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Preop Dx: |
colon CA |
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Labs: |
CBC, chem 7, PT/PTT |
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CXR: |
infiltrate |
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Blood: |
T & C 2 units |
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EKG: |
NSR, wnl |
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Anesthesia: |
preop completed |
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Consent: |
signed and on front of chart |
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Orders: |
1. |
Void OCTOR |
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2. |
1 gm cefoxitin OCTOR |
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3. |
Hibiclens scrub this p.m. |
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4. |
Bowel prep today |
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5. |
- |
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NPO p MN |
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NPO nothing by mouth; OCTOR on call to O.R.; p after; |
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MN midnight |
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OP NOTE
The OP note is written in the progress note section of the chart in the O.R. before the patient is in the PACU (or recovery room).
Example: |
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Preop Dx: |
acute appendicitis |
Postop Dx: |
same |
Procedure: |
appendectomy |
Surgeon: |
Halsted |
Assistants: |
Cushing, Tribble |
OP findings: |
no perforation |
Anesthesia: |
GET |
*I/O: |
1000 mL LR/uo 600 mL |
*EBL: |
50 mL |
Specimen: |
appendix to pathology |
Drains: |
none |
Complications: |
none (Note: If there are complications, |
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ask what you should write.) |
To PACU in stable condition |
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GET general endotracheal; I/O ins and outs; uo urine output; EBL estimated blood loss; PACU postanesthesia care unit
*Ask the anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) for this information.
12 Section I / Overview and Background Surgical Information
How do I remember what is |
Remember the acronym “PPP SAFE |
in the OP note when I am in |
DISC”: |
the O.R.? |
Preop Dx |
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Postop Dx |
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Procedure |
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Surgeon (and assistants) |
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Anesthesia |
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Fluids |
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Estimated blood loss (EBL) |
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Drains |
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IV Fluids |
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Specimen |
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Complications |
POSTOP NOTE |
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The postop note is written on the day of the operation in the progress notes
Example: |
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Procedure: |
appendectomy |
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Neuro: |
A&O 3 |
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V/S: |
wnl/afebrile |
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I/O: |
1 L LR/uo 600 mL |
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Labs: |
postop Hct: 36 |
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PE: |
cor RRR |
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pulm CTA |
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abd drsg dry and intact |
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Drains: |
JP 30 mL serosanguinous fluid |
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Assess: |
stable postop |
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Plan: |
1. |
IV hydration |
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2. |
1 g cefoxitin q 8 hr |
A&O 3 alert and oriented times 3; V/S vital signs; uo urine output; Hct hematocrit; RRR regular rhythm and rate; JP Jackson-Pratt; wnl within normal limits
ADMISSION ORDERS
The admission orders are written in the physician orders section of the patient’s chart on admission, transfer, or postop
Example: |
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Admit to 5E Dr. DeBakey |
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Dx: |
AAA |
Condition: |
stable |
V/S: |
q 4 hr or q shift; if postop, q 15 min 2 hr, |
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then q 1 hr 4, then q 4 hr |
Allergies: |
NKDA |
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Chapter 1 / Introduction 13 |
Activity: |
bedrest or OOB to chair |
Nursing: |
daily wgt; I/O; change drsg q shift |
Call HO for: |
temp 38.5 |
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UO 30 mL/hr |
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SBP 180 90 |
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DBP 100 |
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HR 60 110 |
Diet: |
NPO |
IVF: |
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D5 1/2 NS c 20 KCL |
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Drugs: |
ANCEF |
Labs: |
CBC |
OOB out of bed; I/O ins and outs; HO House Officer; SBP systolic blood pressure; DBP diastolic blood pressure; HR heart rate; KCL potassium chloride
ADMISSION ORDERS/POSTOP ORDERS
“AC/DC AVA PAIN DUD”: Admit to 5E
Care Provider Diagnosis Condition
Allergies
Vitals
Activity
Pain meds
Antibiotics
IVF/Incentive Spirometry
Nursing (Drains, etc.)
DVT prophylaxis
Ulcer prophylaxis
Diet
DAILY NOTE—PROGRESS NOTE
Basically a SOAP note, but it is not necessary to write out SOAP; for many reasons, make your notes very OBJECTIVE and, as a student, do not mention discharge because this leads to confusion
Example:
10/1/90 Blue Surgery POD #4 s/p appendectomy Day #5 cefoxitin
Pt without c/o
14 Section I / Overview and Background Surgical Information
V/S: 120/80 76 12 afebrile (Tmax 38) I/O: 1000/600
Drains: JP #1 60 last shift PE: cor RRR—no m, g, r
pulm CTA
abd BS, flatus, rigidity ext nt, cyanosis, erythema
ASSESS: Stable POD #4 on IV antibiotics PLAN:
1.Increase PO intake
2.Increase ambulation
3.Follow cultures Grayson Stuart, cc III/
Important: Always date, time, and sign your notes and leave space for them to be cosigned!
POD Postop day (Note: The day after operation is POD #1. The day of operation is the operative day. But: Antibiotic day #1 is the day the antibiotics were started.); c/o complains of; nt nontender; cc III clinical clerk, third year
The following is an acronym for what should be checked on your patient daily before rounding with the surgical team: “AVOID WTE”:
Appearance—any subjective complaints Vital signs
Output—urine/drains Intake—IV/PO
Drains—# of/output/character
Wound/dressing/weight
Temperature
Exam—cor, pulm, abd, etc.
INTENSIVE CARE NOTE
This note is by systems:
Neurologic (GCS, MAE)
Pulmonary (vent settings, etc.)
CVS (pressors, swann numbers, etc.)
Heme (CBC)
FEN (Chem 10, nutrition, etc.)
Renal (urine output, BUN, Cr, etc.)
I & D (Tmax, WBC, antibiotics, etc.)
Assessment
Plan